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4^1  ■;!;';;  if;:; 


THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 


GIFT  OF 

SAN  FRANCISCO 
COUNTY  MEDICAL  SOCIETY 


ON 


DISEASES 


PECTJLIAK  TO  WOMEN, 


INCLUDING 


DISPLACEMENTS  OF  THE  UTERUS. 


BY 

HUGH  L.  HODGE,  M.D., 

EMERITCS  PROFESSOR  OF  OBSTETRICS  AND  DISEASES  OF  WOMEN  AND  CHILDREN  IN  THE  I'SIVERSITT 
OF   PENNSYLVANIA. 


'NULLIUS  ADDICTUS  JURARE  IN  VERBA  MAGISTRI." 


WITH    ILLUSTRATIONS. 
SECOND   EDITION,    REVISED    AND   ENLARGED. 


PHILADELPHIA: 

HEIl^RY     O.     LEA 
1868. 


Entered  according  to  Act  of  Congress,  in  the  year  1860,  by 

HUGH    L.    HODGE,   M.D., 

in  the  Office  of  the  Clerk  of  the  District  Court  of  the  United  States  in  and  for  the 
Eastern  District  of  the  State  of  Pennsylvania. 


PHILADELPHIA: 
COLLINS,  PEINTKR,  705  JAYNE  STREET 


Biomedical 
Uknry 


WP 
/?t8 


TO  THE 


ALUMNI 


UNIVERSITY  OF  PENNSYLVANIA, 


598233 


PREFACE  TO  THE  SECOND  EDITION. 


The  former  edition  of  this  work  was  prepared  main]j  for  the 
use  of  the  Alumni  of  the  University  of  Pennsylvania.  The  ob- 
ject of  the  author  was  to  present  more  at  length  and  in  detail 
those  views  on  the  nervous  diseases  of  women  which  he  had  for 
many  years  taught  in  the  halls  of  the  University.  His  opinions 
were  formed  chiefly  from  his  own  observations  and  reflections 
during  an  extensive  practice  of  many  years.  They  were  detailed 
without  much  reference  to  the  opinions  of  others,  under  the  im- 
pression that  thus  the  views  of  the  author  might  be  more  dis- 
tinctly stated,  and  that  their  value  could  be  more  readily  compre- 
hended. This  plan  has  been  maintained  in  the  present  edition, 
although  there  have  been  many  additions  made  to  the  original 
text,  the  result  of  further  observation  and  reflection,  and  of  the 
study  of  many  of  those  excellent  works  which  have  been  so 
rapidly  issued  from  the  press  by  authors  whose  opinions  and 
practice  are  held  in  deserved  estimation. 

As  the  subject  of  metritis  in  its  various  modifications  and  com- 
plications has  given  rise  to  numerous  discrepancies,  both  in  theory 
and  practice,  the  chapter  on  uterine  inflammation  has  been  greatly 
altered  and  enlarged.  The  object  of  the  author  was  not  merely 
to  present  what  he  deems  a  more  correct  theory  and  practice  in 
inflammatory  diseases  of  the  uterus,  but  also  to  insist  that  a  very 
largQ  proportion  of  the  so-called  cases  of  metritis  are  in  reality 
but  examples  of  irritation,  where  inflammation  has  subsided,  or 
where  it  has  actually  never  existed.  Indeed,  the  chief  object  of 
this  whole  work  is  to  exemplify  the  nature,  consequences,  and 
treatment  of  nervous  irritation  as  distinct  from  inflammation. 

In  carrying  out  this  idea,  the  author  has  endeavored  to  show 
that  the  nervous  diseases  of  women,  often  grouped  under  the  word 


VI  PREFACE    TO    THE    SECOND    EDITION. 

"  hysteria,"  can  be  generally  traced  to  the  pelvic  viscera,  and  espe- 
cially to  the  uterus.  The  causes  of  such  disturbances,  whether 
centric  or  eccentric,  are  exceedingly  diversified — the  nervous  sus- 
ceptibility of  women  being  easily  disturbed  by  innumerable  moral 
and  physical  excitements.  Experience  has  convinced  the  author 
that  not  only  is  the  uterus  involved  in  most  of  these  complaints, 
but  that  its  disturbances  are  very  frequently  dependent  upon  dis- 
placements of  the  organ,  however  induced.  Hence,  special  atten- 
tion has  been  given  to  this  subject  of  displacements  of  the  uterus, 
the  more  so,  as  in  the  opinion  of  the  author,  these  displacements 
of  the  uterus  are  of  great  importance,  and  have,  as  he  must  think, 
been  seldom  treated  on  scientific  principles.  One  part  of  this 
work  is  therefore  devoted  to  this  subject. 

The  third  part  is  occupied  with  sedation,  a  condition  of  the 
tissues  in  perfect  contrast  with  that  of  nervous  excitement  or 
irritation. 

Prefixed  to  the  present  edition  of  this  work  is  an  introductory 
chapter,  in  which  the  author  has  endeavored  to  portray  the 
opinions  of  many  high  authorities  on  the  various  subjects  of  ir- 
ritation, congestion,  and  inflammation,  with  their  sequelae  and 
treatment,  in  contrast  to  those  here  advocated.  In  this  manner 
the  difference  of  opinion  and  practice  may  be  more  distinctly  ob- 
served, and  it  is  hoped  some  valuable  truths  may  be  elicited. 

An  enlargement  in  the  size  of  the  page  has  admitted  of  these 
various  additions  without  unduly  increasing  the  bulk  of  the 
volume. 

Numerous  illustrations  from  the  skilful  pencil  of  Mr.  Baxter, 
respecting  the  character  and  treatment  of  displacements  of  the 
uterus  will,  it  is  trusted,  greatly  assist  the  student  in  comprehend- 
ing the  nature  of  such  deviations  and  their  proper  management. 
The  drawings  represent  the  organs  of  one-half  their  natural  size. 
Tbey  have  been  arranged  and  lettered  upon  the  supposition  that 
the  patient  is  recumbent,  on  the  back.  By  turning  the  book, 
the  relative  position  of  the  tissues  and  organs,  in  the  erect  pos- 
ture, can  be  perceived. 

PUILADELPHIA,  August,   1868. 


To  CHARLES  D.  MEIGS,  M.  D., 

PROFESSOR    OF    OBSTETRICS    AND    DISEASES    OF    WOMEN    AND    CHILDREN 
IN    THE    JEFFERSON    MEDICAL    COLLEGE. 

Deae  Doctor: — 

I  embrace  the  first  public  opportunity  of  acknow- 
ledging the  affectionate  and  complimentary  letter,  pre- 
fixed to  your  work  on  the  Diseases  of  Women.  Be 
assured  that  I  fully  reciprocate  your  kind  feelings.  It 
could  not  be  otherwise,  as  we  were  indeed  instructed  by 
the  same  Alma  Mater,  and  have  toiled  together  for 
upwards  of  forty  years  in  the  arduous  and  responsible 
duties  of  our  profession.  The  chain  of  our  friendship 
has  never  been  broken,  or  even  sullied.  You  politely 
urged  me  to  make  a  "s^'^/^"  for  posterity;  I  have  at  last 
ventured  to  make  one — in  the  form  of  the  work  now  sent 
to  you.  I  could  not,  dear  Doctor,  write  as  you  have 
done,  not  having  your  peculiar  spirit ;  and  I  may,  perhaps, 
fall  under  the  lash  of  your  criticism  upon  our  fathers  in 
medicine,  whose  "  dulness  and  jargon"  you  assign  as  a 
reason  why  they  are  not  more  studied  and  appreciated. 
I  have  at  least,  however,  followed  your  examj^le  of 
writing,  currente  calamo,  in  my  own  manner — simple  and 
dull  it  may  be — but  with  a  sincere  desire  to  contribute 
the  results  of  my  observations  and  reflections  towards 
the  improvement  of  medicine.  I  know  well  that  our 
productions — each  characteristic  of  its  author — difter 
exceedingly  in  theory  and  in  practice ;  but,  nevertheless, 


Vlll  TO    CHAKLES    D.    MEIGS,    M.D. 

the  student  who  examines  each  book  may  discover  the 
truth  more  clearly,  and  be  prepared  to  render  such  truth 
more  efficient.  The  very  opposition,  which  may  be  per- 
ceived in  the  vicAVS  of  experienced  men  in  the  profession, 
is  often  beneficial — ex  coUisione  scintilla.  Should  this 
be  the  result,  we  shall  both  rejoice.  Truth  is  our  object 
— that  truth  which  is  practical,  and  which  will  increase 
the  efficiency  of  our  beloved  science  in  alleviating  the 
sufferings  of  our  fellow-beings.  Priiicipia  non  homines 
is  our  motto. 

That  you,  dear  friend,  may  be  long  spared  in  health 
and  strength,  to  carry  on  your  philanthropic  labors,  is 
the  prayer  of 

Yours,  most  truly  and  respectfully, 

HUGH  L.  HODGE. 

November  1,  1860. 


CONTENTS. 


Dedication    . 

Preface 

Letter  to  Dr.  Meigs 

Introdoction 


PAGE 

iii 

V 

vii 
33 


PART    I. 

DISEASES  OF  IRRITATION. 
CHAPTER    I. 


NERVOUS  IRRITATION  AND  ITS  CONSEQUENCES. 

Definitions  and  illustrations  ...... 

.      69 

Irritability- 

.      70 

Organic  and  nervous  irritation 

.      75 

Congestion     . 

.      76 

Passive    . 

.      76 

Active    . 

.      77 

Inflammatory  or  organic 

77 

Simple  or  nervous  . 

77 

Neuralgia 

84 

Vital  power   . 

88 

Ansemia 

93 

Toxicaemia     . 

95 

General  conclusions 

96 

CHAPTER    II 

IRRITABLE  UTERUS. 


Definition       .... 
Opinions  of  pathologists 
Supposed  diflBculty  of  treatment 
Neuralgia,  hysteralgia,  etc.    . 
Irritable  diseases  really  physical  ailments 
All  pain  is  nervous  irritation 


99 
100 
101 
101 
101 
104 


CONTENTS. 


CHAPTER  III, 


LOCAL  SYMPTOMS  OF  IRRITABLE  UTERUS. 


PAGE 

Pain  and  distressing  sensations     ......     105 

Aggravated  by  motion 

.     107 

Aggravated  by  menstruation,  etc. 

.     109 

Simple  dysmenorrbcea    . 

.     109 

Congestion    .... 

.     113 

Hypertrophy  . 

.     115 

Menorrhagia  and  hsemorrhagia 

.     117 

Leucorrhcea    . 

.     118 

Functional  leucorrhcea    . 

.     119 

Inflammatory  leucorrhcea 

.     122 

Dysmenorrhoea 

.     122 

Congestive  dysmenorrhoea 

.     122 

Mechanical  dysmenorrhoea 

.     123 

Membranous  dysmenorrhoea. 

.     126 

CHAPTER    lY 


LOCAL  SYMPTOMS  OF  IRRITABLE  UTERUS — COnt 

imied. 

COMPLICATIO 

NS. 

Inflammation            ....            ... 

130 

Metritis  ..... 

130 

Cervical  endometritis  . 

133 

Cervico-metritis 

137 

Strictures  of  the  cervix  . 

138 

Corporeal  endometritis 

139 

Corporeal  metritis 

140 

Pelvic  peritonitis 

147 

Irritability  after  inflammation 

151 

Errors  in  theory  and  practice 

151 

Tractability  of  these  inflammations  . 

154 

Treatment  of  metritis  and  its  varieties 

156 

General  conclusions    . 

165 

Tumors  and  other  complications    . 

166 

CHAPTER    V 


GENERAL  SYMPTOMS  OF  IRRITABLE  UTERUS. 


Cerebro-spinal  irritations 
Spinal  irritation 
Cerebral  irritation 
Languor 


168 
168 
169 
171 


CONTENTS. 


XI 


Irritations  along  particular  nerves     .... 

Hyperesthesia  of  the  skin  .... 

Symptoms  vary,  and  may  be  confined  to  one  side  of  the  body 
Cerebral  disturbances  ..... 

Convulsions  ...... 

Delirium  ...... 

Intellectual  and  moral  disorders 


PAliE 

.     172 

.    173 

.     174 

.     174 

.     175 

.     175 

.     176 

CHAPTER   VI. 

GENERAL  SYMPTOMS  OP  IRRITABLE  UTERUS — COntimied.    REFLEX  INFLUENCES 
OF  CEREBRAL  AND  SPINAL  IRRITATION. 


Sympathy  and  reflex  action 

External  organs 

Internal  organs 
Pharynx 
Larynx 

Organs  of  the  chest    . 
Respiratory  function 
Coughs 
Aphonia 
Heart 
Mammae 
Viscera  of  the  abdomen 
Liver 
Stomach 

Tympanites  . 
Intestines 
Kidneys    . 

Organic  life  sometimes  involved 


181 

182 

183 
183 
184 
184 
184 
185 
186 
187 
188 
189 
189 
190 
191 
196 
199 

200 


CHAPTER   VII 


progress  and  results  of  irritable  uterus. 
Irritable  rectum     .... 
Irritable  vulva  and  vagina  (vaginismus) 
Irritable  bladder  and  urethra 
Irritations  and  enlargements  of  the  ovaries 
Irritations  of  lymphatic  glands 
Irritations  of  the  pelvic  nerves 
Conclusions  .... 


206 
208 
211 
215 
219 
221 
222 


Xll 


CONTENTS. 


CHAPTER   YIII 


CAUSES   AND   PATHOLOGY   OF   IRRITABLE    DISEASES. 


Predisposing  causes 

Nervous  temperament 

Rheumatism  and  gout 

The  parturient  state 

Displacements  of  the  uterus 

Climate 

General  conclusions 

Exciting  causes 

Inflammatory  congestion 

Parturition 

Over-lactation  .  .    . 

Nimia  Venus 

Mental  and  moral  excitements 

Cold    .... 

Great  muscular  effort 

Pressure 

Diseases  of  the  uterus 

Obstructions,  partial  or  complete,  of 

Irritations  of  other  organs     . 

General  conclusions 

Pathology 

Diagnosis      .... 

Prognosis      .... 


the  cervix  uteri 


CHAPTER    IX 


TREATMENT   OF   IRRITABLE   UTERUS 


Removal  or  Palliation  of  the  cause 
Congestions  of  the  uterus 
Acute  inflammation 
Chronic  inflammation 
Enlargements 

Hypertrophy 
Induration 
General  conclusions    . 
Rheumatic  or  gouty  irritations 
Parturient  state 
Lactation 


CONTEXTS. 


XI 11 


Indulgence  of  the  appetites 

Excitement  of  the  mind 

Cold 

Displacements  of  the  uterus 

Sj'mpathetic  Disturbances 

General  remarks 


PAGE 

255 
257 
257 
257 

258 
258 


CHAPTER    X. 

TREATMENT    OF   IRRITABLE   UTERUS — continued. 


Hygienic  measures 

.    263 

Food                .            .            .            . 

.     263 

Laxatives 

.     264 

Tonics 

.     264 

Fresh  and  pure  air     . 

.     266 

Water 

.     266 

Warm  water  baths 

.     267 

Cold  water  baths 

.     268 

Exercise  and  rest 

.    270 

Conclusions     . 

.    274 

Medicinal  agents    . 

•    275 

Acute  cases    . 

.    275 

Loss  of  blood 

.     275 

Revulsives 

.     276 

Narcotics 

.    276 

Chronic  cases 

.    277 

Loss  of  bipod 

.     277 

Warm  water 

.     277 

Cold  water 

.    278 

Narcotic  applications 

.     279 

Applications  of  nitrate  of  silvei 

.    280 

Mechanical  measures 

.     281 

General  remarks     . 

.    281 

CHAPTER    XI 


TREATMENT    OF    THK    UUMJr'LlUAXiUi.Na    uj;    itiriiiAisuEj 

Menstrual  disturbances     ..... 

Ui.£itVU>3. 

.     284 

Dysmenorrhoea               .            .             .            •             . 

.     284 

During  the  interval         .... 

.     284 

During  the  paroxysm      .... 

.     288 

Menorrhagia  ...... 

.     289 

Removal  of  the  local  irritation  . 

.     290 

Palliative  measures          .... 

.     294 

XIV 


CONTENTS, 


Leacorrhcea    •  .  .  . 

Removal  of  the  irritation 
Palliative  measures 

Infi^mmation  .... 

Acute  inflammatioa 
Chronic  inflammatioa 

General  measures  and  local  applications 

Eemoval  of  the  irritation 

Rheumatic  and  gouty  affections    . 


PA<tB 

2'.)5 
2% 
296 

296 

297 
297 
297 
297 

298 


CHAPTER   XII. 

TREATMENT  OF  THE  COMPLICATIONS  OF  IRRITABLE  UTERrS- 
SECONDARY  AND  SYMPATHETIC  AFFECTIONS. 

Irritable  rectum      .... 

Irritable  tulta  and  tagina  (Yaginismus) 

Irritable  bladder  and  urethra 
Removal  of  the  cause 
Palliative  remedies     . 

Morbid  states  of  the  ovaries 

Irritable  lymphatic  glands 

Irritation  of  the  pelvic  nerves 

General  remarks 


rontinued. 


301 

302 

304 
305 
306 

307 

309 

309 

310 


PAET   II. 

DISPLACEMENTS  OF  THE  UTERUS. 
CHAPTER    I. 


NATUR-iL   POSITION   AND   SUPK)RT8   OF   THE   UTERUS. 


Natural  position  of  the  uterus 
The  cavity  of  the  pelvis 
Pelvic  nerves 
The  uterus 

Situation  and  direction 
Mobility  of  the  uterus 


314 
314 
314 
316 
316 
319 


CONTEXTS. 

XV 

,        PAtiE 

Supports  of  the  uterus     .......    319 

The  vagina     .... 

.     320 

Ligaments       .... 

.     321 

Broad  ligaments  . 

.     322 

Round  ligaments 

.     322 

Utero-vesical  ligaments  . 

.     324 

Utero-sacral  ligaments     . 

.     324 

General  remarks 

^ 

.     325 

Accessory  agents    . 

.     326 

Pelvic  fascia  . 

.     326 

The  levatores  ani  muscles 

.     326 

Pressure  of  the  small  intestines 

.     327 

Obliquity  of  the  pelvis 

.     328 

General  remarks     . 

.     329 

CHAPTER    II 


VARIETIES   OF   DISPLACEMENTS   OF   THE   UTERUS,    AND   THEIR   CAUSES. 


Varieties 

Prolapsus 

Complications 
Anteversion    . 

Complication 
Retroversion  . 

Complication 
Procidentia     . 


Causes 


Predisposing  causes 

Relaxation  of  the  ligaments  and  of  the  reflected  peh 

Increased  size  and  weight  of  the  uterus 

Distension  of  the  abdomen 

Pressure  on  the  abdomen 

Menorrhagia,  etc.  .... 

Exciting  causes         ..... 

Muscular  effort  ..... 

Tumors,  etc.        ..... 

The  character  of  the  displacement    . 


.  330 

.  330 

.  332 

.  332 

.  334 

.  334 

.  336 

.  338 

.  339 

.  340 

fascia  340 

.  340 

.  341 

;  341 

.  342 

.  342 

.  343 

.  343 

.  344 


CHAPTER    III 


symptoms  of  displacements  of  the  uterus. 
dlsplaceme.nts  may  exist  with  impunity  . 

Displacements  generally  cause  inconvenience  . 

Local  symptoms  ..... 


346 

348 
348 


XVI 


CONTENTS. 


General  symptoms      .... 
Conclusions     ..... 

Symptoms  aggravated  if  the  uterus  be  sensitive 
Practical  deductions  .... 

Diagnosis      ...... 

Special  symptoms        .... 
Vaginal  examinations 

Anatomical  facts 

Mode  of  making  the  examination 

Importance  of  displacements 

Prognosis     ...... 


CHAPTER    lY 


TREATMENT   OF  DISPLACEMENTS   OF   THE   UTERUS 

To  remove  or  palliate  any  existing  causes 
Transitory  causes 
Persistent  causes 
Remarks  .... 

To  REPLACE  THE  UTERUS  IN  ITS  NATURAL  POSITION 

Elevators        .... 
Remarks  .... 

To  maintain  the  uterus  in  its  NATURAL  POSITION 

Rest  in  bed     .... 
Rest  conjoined  with  astringents 
Operations  upon  the  vagina  . 
External  bandages 

Objections 

Minor  objections 

Hypotheses  of  their  action 

Mere  palliatives 

How  they  afford  relief     . 


CHAPTER    V. 

TREATMENT  OF  DISPLACEMENTS— COW^mwec?.      INTERNAL  SUPPORTERS. 


Value  of  pessaries     . 
Objections  to  pessaries 
Indications  to  be  fulfilled 

Material 
Form  of  the  instrument 

Globular  pessaries 


CONTENTS. 


xvn 


Concavo-convex  pessaries 

Plano-convex  pessaries 

Air-pessaries 

Ring-pessaries 

Stem-pessaries 

Simpson's  intra-uterine  pessaries 

Simpson's  intra-uterine  pessary  modified 

CHAPTER    VI 

TREATMENT  OP  DISPLACEMENTS — continued. 

Varieties 

Open  lever 

Modus  operandi 
Closed  lever 
Introduction  and  removal 

Introduction  of  open  lever 
Eemoval  of  open  lever 
Introduction  of  closed  lever 
Removal  of  closed  lever 
General  remarks     . 
Conclusions    . 


LEVER  PESSARIES. 


PAGB 

393 
395 
397 
397 
401 
402 
410 


414 
414 
414 
419 
423 
423 
424 
425 
426 

427 
434 


CHAPTER   VII 

TREATMENT  OP  THE  VARIETIES  OP  DISPLACEMENTS 

Varieties 

Prolapsus 

Anteversion    . 

Retroversion 

Procidentia     . 
Displacements  of  the  vagina,  etc. 

Prolapsus  of  the  vagina,  etc. 
Hernia  op  the  bladder 
Strengthening  of  the  natural  supports  of  the  uterus 


435 
435 
435 
437 
439 
440 
440 
442 
444 


CHAPTER  VIII. 

treatment  op  complications  of  displacements  op  the  uterus. 

Flexion         .........  447 

Menstrual  disturbance      .......  448 

Enlargements  and  tumors  of  the  uterus  ....  449 

Hypertrophy  ........  449 

Tumors  .  .  .  .  .  .  .  •  451 

2 


XVlll 


CONTENTS. 


Pessaries 
Antiphlogistics 
Alteratives 
Excision 


PAGE 

454 
455 
456 
456 


CHAPTER   IX. 


TREATMENT  OF  ENLARGEMENTS  AND  DISPLACEMENTS  OF  THE  OVARIES,  ETC. 


Enlargements  of  the  ovaries 
Diagnosis 
Pathology 
Displacements 
Complications 

Anomalous  cases 

Treatment  . 


464 
464 
465 
467 
468 

477 

478 


PART    III. 

DISEASES  OF  SEDATION. 


CHAPTER    I. 


SEDATION  AND  ITS  CONSEQUENCES. 


Organic  sedation        .            .            .            ... 

.    482 

Nervous  sedation       ..... 

.    482 

Causes            ...... 

.    483 

Indirect           ..... 

.    484 

Direct ...... 

.    484 

Consequences  of  sedation   ,           .           .           .  ^ 

.    484 

Influence  of  nervous  sedation  on  organic  actions 

.    485 

Influence  of  organic  sedation  on  nervous  actions 

.    485 

Passive  congestion 

.    485 

Reaction          ..... 

.    487 

Treatment     ...... 

.    487 

Stimulation     ..... 

.    487 

Direct  stimulation 

.    488 

Indirect  stimulation 

.    488 

CONTENTS. 


XIX 


CHAPTER    II. 

SEDATION  OF  THE  UTERUS — AMENORRHffiA. 


PAOB 

Sedation  from  moral  causes 

.    492 

Sedation  from  physical  causes 

.    493 

Asthenia 

.     496 

Organic  diseases 

.     498 

Eheumatism  and  gout 

.    499 

Fevers  and  phlegmasiae 

.     501 

Nervous  irritations     . 

.     .501 

Cold     .... 

.     505 

Conclusions  .... 

.    507 

CHAPTER    III 


DIAGNOSIS  AND  TREATMENT  OF  SEDATION  OF  THE  UTERUS. 

Diagnosis 

Prognosis 

Treatment     . 

Removal  of  the  cause 

Asthenia  . 

Organic  diseases 

Rheumatism,  gout,  etc 

Fevers  and  inflammations 

Mental  and  moral  disturbances, 
Cups  and  leeches 
Fomentations,  etc. 
Revulsives  or  derivatives 
Laxatives 
Rubefacients  . 
Local  stimuli  . 
Emmenagogues 

General  remarks 


exposure  to  cold,  etc. 


509 

511 

511 
512 
512 
512 
512 
512 
512 
513 
514 
514 
515 
515 
516 
518 

523 


ON   DISEASES 
PECULIAR   TO   WOMEN 


INTRODUCTION. 

In  preparing  and  publisliing  the  former  edition  of  tliis  work, 
the  author  acted  under  the  belief  that  the  best  mode  to  improve 
the  science  and  practice  of  the  profession  was  that  each  indi- 
vidual of  experience  should  present,  as  concisely  as  possible,  the 
results  of  his  own  observations  and  reflections.  His  opinions,  if 
intermingled  with  those  of  others,  can  be  less  distinctly  expressed, 
and  would  often  but  reiterate  the  sentiments  of  authors  well 
known.  Thus,  any  real  contribution  to  the  science  of  medicine 
might  be  lost,  or  at  least  rendered  nugatory,  by  the  weight  of 
high  authorities,  especially  if  such  contribution  should  be  in 
direct  opposition  to  the  prevailing  theories  and  practice  of  the 
profession. 

"Without  laying  any  special  claims  to  originality  in  the  follow- 
ing essay,  nevertheless,  the  broad  statements  of  doctrines  pro- 
pounded, their  issues,  and  especially  their  practical  results,  are, 
to  a  great  degree,  peculiar,  and,  in  the  opinion  of  the  author, 
exceedingly  beneficial.  He  must  believe  that  the  practice,  incul- 
cated in  the  treatment  of  the  nervous  diseases  of  women,  has 
proved,  and  will  prove  more  favorable  than  that  usually  recom- 
mended. Hence,  much  suffering  will  be  mitigated  or  destroyed, 
great  mental  and  moral  disturbances  dissipated,  and  much  time 
saved  in  the  treatment  of  these  maladies. 

In  presenting,  however,  a  new  edition  of  the  work,  it  may  be 
advantageous  to  point  out  some  of  the  opinions  of  leading 
authorities  in  a  succinct  manner,  so  that  the  difference  which 
3 


34  INTRODUCTION". 

may  exist  between  them  and  those  of  the  author  may  be  the 
more  readily  and  distinctly  comprehended. 

Irritability. — The  first  important  question  is  whether  "irrita- 
bility" be  a  morbid  state,  irrespective  of  any  other  lesion.  When 
this  idea  was  promulgated  by  Mr.  Brodie  and  Dr.  Gooch  it  re- 
ceived vehement  opposition,  and  although  such  a  state  of  disease 
is  now  very  generally  recognized,  even  by  former  opponents,  yet 
still,  few  systematic  writers  speak  of  it  as  a  distinct  affection,  as 
different  from  inflammation;  even  when  they  acknowledge  its 
existence,  they  trace  it,  almost  invariably,  to  a  phlogosed  condition 
of  the  tissues,  or,  at  any  rate,  assert  that  it  is  but  the  predecessor 
or  successor  of  inflammatory  action.  Thus  Dr.  Tilt,  in  his  valu- 
able work  on  the  Diseases  of  the  Ovaries,  declares  that  irritability  of 
an  organ  constitutes  a  "scapegoat"  of  modern  pathologists;  yet,  in 
many  instances,  he  acknowledges  the  existence  of  this  condition 
in  various  tissues  or  organs  of  the  body;  thus,  he  speaks  of  an 
irritable  condition  of  the  bladder,  rectum,  stomach,  intestines, 
etc.,  although  he  insists  that  such  irritability  may  be  followed  by 
inflammation.  He  speaks,  also,  of  pruritus  vulvae  as  being  often 
present  without  any  inflammation. 

The  incongruity  between  the  positive  assertion  that  irritability 
has  no  existence  per  se,  and  yet  that  it  is  found  in  different  tissues, 
is  common  with  all  authors ;  perhaps  we  may  say  it  is  universal. 
Even  Dr.  Bennett,  who  declares  that  irritabilit}''  of  the  uterus  is 
but  another  name  for  inflammation,  speaks  of  sympathetic  irrita- 
tion in  the  ovaries,  stomach,  bowels,  brain,  etc.  Hence  dyspepsia, 
cephalalgia,  and  other  neuralgic  affections  arise  from  inflamma- 
tion of  the  cervix  uteri. 

Professor  Byford,  of  Chicago,  who  indorses  Dr.  Bennett's 
opinions,  even  asserting  that  pain  in  the  uterus  is,  in  all  cases, 
indicative  of  inflammation,  nevertheless  describes  states  of  hyper- 
ajsthesia  of  the  skin,  especially  that  portion  over  the  mammae,  and 
also  as  affecting,  in  many  cases,  the  glandular  tissue  of  these 
organs  with  more  or  less  tumefaction ;  and  yet  this  state  of  mas- 
todynia,  neuralgia  of  the  breast,  may  exist  for  very  many  years 
without  any  structural  derangement.  It  is  aggravated,  he  affirms-, 
by  the  occurrence  of  the  menses,  by  pregnancy,  &c.,  and  is  very 
indomitable,  although  it  often  disappears  when  the  inflammation 
of  the  uterus  is  allayed.  If  this  state  be  true  of  the  mammae,  why 
not  of  the  uterus  ? 


IRRITABILITY.  35 

The  distinguished  German  pathologist,  Professor  Scanzoni, 
who  believes  that  "engorgement"  or  inflammation  is  very  univer- 
sally the  cause  of  irritation  of  the  uterus,  yet  declares  that  he 
has  met  with  three  distinct  cases  of  hysteralgia,  where  no  lesion 
could  be  detected.  He  also  describes  hypereesthesia  of  the  skin 
and  mammae,  aggravated  by  menstruation,  which  he  regards  and 
treats  as  an  hysteric  affection,  by  tonics,  antispasmodics,  anodyne 
liniments,  etc. 

Dr.  Laycock,  in  exemplifying  the  mutual  influence  of  the  ova- 
ries and  mammge  upon  each  other,  states  that  the  latter  are  often 
very  much  enlarged,  as  well  as  more  sensitive,  from  ovarian 
excitements. 

Sir  James  Y.  Simpson,  whose  authority  is  so  eminent,  declares 
that  all  the  severe,  local,  and  general  symptoms  characterizing 
uterine  complaints  may  exist  with,  and  also  without,  any  organic 
or  local  lesion ;  that  often  they  exist  for  years  in  the  most  aggra- 
vated form,  where  certainly  there  is  no  organic  disease  whatever, 
as  in  cases  of  irritable  uterus  or  hysteralgia.  He  gives  a  graphic 
detail  of  the  almost  innumerable  sympathetic  disturbances  in 
distant  tissues  and  organs,  traceable,  he  believes,  to  the  uterus ; 
hence,  hypersesthesia  of  the  surface  of  the  body,  neuralgia  in 
various  nerves  of  the  extremity  and  trunk,  disturbances  of 
the  brain,  violent  headaches — often,  also,  mental  and  moral 
hallucinations,  palpitations  of  the  heart,  asthma — also  disturb- 
ances of  the  stomach  and  bowels,  of  the  mammee,  etc.  All 
these,  and  other  analogous  functional  disturbances,  are  without 
inflammation  or  organic  lesion ;  they  disappear  when  the  uterine 
irritation  or  disease,  whatever  it  may  be,  is  removed ;  they  all 
may  be  considered  examples,  therefore,  of  morbid  irritability. 

Dr.  Churchill,  whose  works  are  held  in  the  highest  esteem, 
subscribes  to  Dr.  Gooch's  idea  of  irritable  uterus,  giving  rise  to 
neuralgia  of  this  organ,  dysmenorrhoea,  and  to  other  local  as  well 
as  sympathetic  disturbances. 

Dr.  Graily  Hewitt,  now  one  of  the  leading  practitioners  of 
England,  fully  indorses  the  idea  of  the  irritability  of  an  organ 
without  inflammation.  One  of  its  most  common  manifestations 
is  pain ;  he  dwells,  therefore,  much  on  pelvic  pain,  the  location 
of  which  varies,  being  sometimes  in  the  neck,  sometimes  in  the 
body  of  the  uterus,  and  often  in  the  ovaries ;  and,  in  either  case, 
it  may  exist  without  any  appreciable  change  in  the  organism  of 


36  INTRODUCTION.' 

the  parts.  He  quotes,  therefore,  with  approbation  Negrier's 
opinion,  that  "  hysterical  pain" — that  is,  pain  without  inflamma- 
tion— is  very  generally  to  be  referred  to  the  ovaries ;  the  result 
of  irritation  without  inflammation,  or  rather  lesion;  he  terms  it 
"  ovarie,"  and  it  is  to  be  distinguished  from  follicular  ovaritis. 
Dr.  Hewitt  considers  this  as  a  state  of  hypertesthesia,  or  excited 
condition  of  the  ovary,  very  often  dependent  upon  mere  sexual 
excitement,  and  not  referable  to  inflammation  of  the  cervix  uteri, 
or  to  any  displacement,  etc.  of  the  ovary.  So  also  "  hysterical 
pain,"  sometimes  perceived  in  the  skin,  in  the  mammjB,  in  the 
spine,  even  in  the  extremities,  is  referable  to  the  same  state  of 
nervous  excitement,  and  probably  connected  with  the  ovaries,  if 
not  with  the  condition  of  the  uterus  itself. 

Dr.  West,  one  of  the  most  careful  and  judicious  authors  of  the 
day,  and  who,  by  his  patient  analysis  of  phenomena,  has,  in  a 
great  degree,  disabused  the  public  mind  respecting  the  frequency 
of  ulceration  of  the  os  and  cervix  uteri,  also  declares  that  a 
morbid  sensibility  of  the  organs  is  very  common  in  women, 
giving  rise  not  merely  to  pain,  but  to  the  disturbance  of  the 
functions  of  such  organs ;  and  in  some  instances,  it  may  be,  to  an 
alteration  of  texture.  Dr.  West  also  alludes  to  the  well-known 
fact  that  irritations  of  the  uterus  are  often  reflected  to  distant 
tissues  and  organs, 

Mr.  Waller  speaks  of  irritable  uterus  under  the  head  of  neu- 
ralgia of  this  organ  ;  it  is  characterized  by  intense  suffering — as 
being  verj  indomitable — as  not  accompanied  by  any  appreciable 
alteration  of  tissue;  and  it  is  of  very  uncertain  duration,  yet 
often  disappearing,  and  the  functions  of  the  organs  are  resumed 
without  detriment  and  without  alteration  of  tissue. 

M.  Colombat  believes  that  hysteralgia  represents  pain  more  or 
less  severe  in  the  uterus,  often  with  sympathetic  disturbances  in 
other  organs,  and  not  unfrequently  with  some  congestion  of  the 
uterus,  with  leucorrhoea,  etc. ;  and  yet  where  there  is  no  inflam- 
mation. 

Dr.  Meigs  considers  hysteria  as  ultimately  involved  with  the 
condition  of  the  uterus  and  ovaries  and  with  the  aphrodisiac  state, 
often  giving  rise  to  congestions,  yet  without  inflammation.  He 
however  recommends,  in  some  instances,  the  lancet  for  the  relief 
of  these  engorgements,  although  his  usual  treatment  is  antispas- 
modic. 


CONGESTION".  37 

Dr.  Ingleby  insists  upon  the  existence  of  irritability  of  the 
uterus  and  of  the  vagina  as  distinct  from  chronic  inflammation. 
From  this  it  is  distinguished  by  the  severity  of  the  pain,  by  the 
absence  of  inflammatory  discharges,  by  the  deficiency  of  menstrua- 
tion and  the  non-existence  of  induration  of  the  tissues,  or  even  any 
great  tumefaction.  Dr.  Ingleby  originally  received  Dr.  Gooch's 
views  with  implicit  confidence ;  but  now  considers  him  as  rather 
too  exclusive,  because  he  thought  that  local  diseases  were  always 
absent:  but,  says  Dr.  Ingleby,  there  may  be  abrasions  of  the  os 
uteri,  displacements  of  the  uterus  or  of  the  ovaries,  distensions 
of  the  uterus,  or  fibrous  tumors  in  its  tissue. 

This  criticism  of  Dr.  Ingleby  is  perfectly  correct,  and,  at  the 
same  time,  important ;  for  while  we  contend  for  the  existence  of 
an  irritable  uterus  or  ovary,  without  any  inflammation  or  appre- 
ciable lesion  as  a  fact,  not,  we  think,  to  be  denied,  yet  it  is  equally 
true  that  the  cause  of  such  irritability  may  exist  in  the  very  tis- 
sues which  are  involved.  Thus,  the  uterus  may  be  excessively 
irritable,  because  it  is  displaced,  because  it  is  distended  with  some 
fluid,  or  its  walls  may  be  irritated  by  tubercular  or  fibrous  de- 
velopments ;  or  the  cervix  uteri  may  be  irritated  by  pressure, 
or  by  actual  inflammation.  So  also  an  irritable  uterus  may  be 
complicated  with  inflammatory  affections  of  its  own  or  adjacent 
tissues :  the  two  forms  of  irritation,  organic  and  nervous,  being 
then  coexisting. 

The  duty,  therefore,  of  the  practitioner  is  to  analyze  each  indi- 
vidual case,  determine  whether  it  be  simple  or  complicated,  and 
thus  be  prepared  to  address  his  therapeutical  measures  with  pre- 
cision to  the  peculiarities  of  the  case. 

From  this  array  of  authorities,  it  may  fairly  be  inferred  that, 
under  various  names,  the  idea  of  a  morbid  irritability  of  the  tissues 
without  any  inflammatory  or  other  lesion,  is  a  very  common  afiec- 
tion.  It  often  exists  without  any  perceptible  alteration  in  the 
condition  of  the  parts ;  it  is  a  morbid  state  of  exaltation  of  the 
nerves,  a  state  of  hyperaesthesia,  frequently  excited  by  mental 
and  moral  causes,  as  well  as  by  physical  disturbances,  and  yet 
involving  almost  exclusively  the  nervous  system. 

Congestion,  Engorgements.— Agam,  local  and  appreciable  lesions 
may  exist.  These  may  often  be  the  sequence  of  an  irritable  con- 
dition of  the  organ,  and,  perhaps,  in  all  cases  will  aggravate  the 
symptoms  of  irritation.     Hence,  vascular  fulness  or  congestion 


38  INTRODUCTION. 

not  iinfrequently  ensues.  In  otlier  cases,  from  accidental  or 
secondary  causes,  inflammation  may  be  excited,  which  may  thus 
complicate  previous  nervous  and  vascular  engorgement. 

Hence,  congestion  or  engorgement  of  the  bloodvessels  very  fre- 
quently is  observed.  Here,  however,  unfortunately,  great  dis- 
crepancies exist  in  the  minds  of  pathologists.  The  author  has 
adopted  the  old  distinction  of  active  and  passive  congestion;  the 
former  being  described  as  an  active  determination  of  blood  to  a 
part,  and  the  latter  as  the  arrest  or  partial  stagnation  of  blood  in 
a  part;  the  former  variety,  therefore,  being  essentially  an  arterial 
congestion,  the  latter  a  venous  congestion. 

It  is  unfortunate,  however,  that  these  distinctions  are  not  pre- 
served by  many  leading  authorities ;  the  word  ■passive,  for  example, 
being  attached  to  a  moderate  or  chronic  inflammation  where  the 
part  or  the  general  system  is  debilitated :  passive  congestion, 
therefore,  in  this  sense,  is  the  representative  of  a  weak  or  mild 
inflammation  ;  and  not  indicative,  therefore,  of  an  arrest  or  delay 
of  venous  blood  in  a  part,  independently  of  a  phlogosed  state. 
This  we  deem  an  unfortunate  circumstance,  as  destroying  the  pre- 
cision which  should  characterize  scientific  language. 

As  to  active  congestion,  the  author  has  endeavored  to  prove  that 
there  are  two  varieties,  one  dependent  mainly  upon  the  excite- 
ments of  the  nervous  system,  and  the  other  upon  those  of  organic 
life.  The  prototype  of  the  former  is  observed  in  all  those  phy- 
siological actions  where  there  is  a  sudden  determination  or  rush 
of  blood  to  a  part,  as  in  blushing,  crying,  erections,  etc. 

It  is  contended  also,  in  the  text,  that  the  consequences  of  these 
congestions,  although  often  apparently  similar,  are  entirely 
diverse,  at  least  in  one  important  particular.  Congestion  from 
nervous  irritation  does  not,  per  se,  cause  inflammation  even  when 
it  has  existed  for  a  long  time. 

As  will  be  presently  seen,  authors  practically  recognize, 
although  not  in  so  many  words,  these  two  kinds  of  morbid  tur- 
gescence  of  the  bloodvessels,;  but  they  differ  exceedingly  as  to 
their  proper  character,  their  consequences,  and,  of  course,  as  to 
their  therapeutical  indications.  With  a  large  number  no  distinc- 
tion is  drawn  between  engorgement  or  congestion,  and  actual 
inflammation  ;  while  in  others,  if  nervous  congestion  be  admitted, 
it  is  regarded  as  temporary,  and  very  soon  resulting  in  actual  in- 
flammation, of  which,  therefore,  it  is  but  a  preliminary  stage;  and 


CONGESTION.  39 

hence,  all  nervous  irritations,  with  their  consequent  congestions, 
are  treated  mainly  by  antiphlogistic  measures.  Inflammation  is 
the  root  of  the  evil,  and  it  must  be  destroyed,  even  if  needs  be, 
by  the  most  powerful  agents,  although  the  patient  may  be  ex- 
hausted, adynamic,  anaemic,  demanding  nutritious  diet,  tonics,  and 
stimuli.  This  we  believe  to  be  an  essential  error  in  pathology, 
leading  to  bad  practice.  We  quote,  therefore,  a  few  authorities 
in  support  of  this  assertion,  and  to  prove,  as  we  think,  the  import- 
ance of  drawing  the  distinction  between  the  nervous  and  organic 
varieties  of  active  congestion. 

Dr.  Dewees,  although  among  the  first  to  adopt  from  Dr.  Gooch 
the  idea  of  irritable  uterus,  which  he  well  describes,  speaks  of  it 
as  being  analogous  to  sub-inflammation,  and  to  be  treated  by  anti- 
phlogistic measures.  Dr.  Meigs,  who,  as  we  have  seen,  recognizes 
an  hysteric  condition  of  the  tissues,  asserts  that  the  lancet  is  neces- 
sary for  the  relief  of  the  engorgement.  Even  Dr.  Gooch  himself, 
although  theoretically  correct,  was  practically  wrong,  insisting 
upon  perfect  rest  and  moderate  antiphlogistic  measures. 

In  an  interesting  debate  which  occurred  in  the  French  Academy 
of  Medicine  in  the  year  184:9,  there  was  rather  a  painfal  exhibi- 
tion of  the  discrepancy  of  opinion  among  leading  pathologists  as 
to  the  nature,  consequences,  and  treatment  of  uterine  affections, 
which  unfortunately  has  not  been  materially  dissipated  even  at 
the  present  time.  To  M.  Eecamier  is  given  the  credit  of  asserting 
that  engorgements  of  the  uterus  were  analogous  to  those  observed 
in  "  erectile  tissues."  This  general  idea,  although  not  entirely 
deserted,  was  in  effect  abandoned  by  every  speaker.  Thus  M. 
Velpeau  declared  that  he  had  no  idea  of  engorgement  without 
inflammation.  M.  Lisfranc,  so  well-known  as  a  pathologist, 
treated  all  his  uterine  cases  by  direct  and  powerful  antiphlogistic 
measures.  M.  Hervez  de  Chegoin  thought  that  engorgements,  the 
character  of  which  is  not  mentioned,  often  depend  upon  displace- 
ments and  very  often  upon  inflammations  and  ulcerations  of  the 
cervix,  demanding  antiphlogistics.  M.  Malgaigne  was  of  the 
opinion  that  there  was  often  much  local  disease  with  or  without 
displacement,  and  although  actual  ulceration  was  infrequent,  yet 
when  engorgement  was  present,  he  recommended  the  actual 
cautery.  M.  Moreau  was  one  of  the  very  few  who  acknowledged 
that  engorgement,  of  what  kind  was  not  mentioned,  may  exist 
without  any  displacement,  or  inflammation,  or  alteration  of  tis- 


40  INTRODUCTIOlSr. 

sues.  M.  Jobert  divided  engorgements  into  idiopathic  or  sympto- 
matic; in  the  former,  local  treatment  is  absolutely  necessary;  he 
preferred  the  actual  cautery.  This  severe  remedy  he  is  reported 
to  have  used  very  extensively  and  perseveringly  to  the  termina- 
tion of  his  professional  career,  and  his  influence  has  greatly  pro- 
moted its  adoption.  M.  Eobert  referred  engorgements  to  granular 
states  of  the  cervix  uteri.  M.  Eoux  declared  that  these  engorge- 
ments would  often  terminate  in  cancerous  or  other  degenerations. 
M.  Amussat  also  maintained  that  when  local  measures  were  requi- 
site for  engorgement,  caustics  were  necessary ;  he  gave  preference 
to  potassa  cum  calce  over  the  actual  cautery.  Another  question 
was  involved  in  the  debate  whether  affections  of  the  uterus  were 
primary  or  secondary.  M.  Baud  considered  that  they  generally 
depended  upon  certain  constitutional  states,  and,  therefore,  consti- 
tutional remedies,  especially  tonics,  were  of  prime  importance,  and 
that  local  astringents  or  corroborants  would  ameliorate  the  symp- 
toms. M.  Gibert  was  much  of  the  same  opinion,  insisting  that 
uterine  affections  were  too  much  magnified,  that  treatment  was 
unnecessarily  severe,  and  that  all  the  symptoms  said  to  be  charac- 
teristic of  uterine  irritation  might  exist  in  a  perfectly  healthy 
condition  of  the  organ.  M.  Paul  Dubois,  who  seemed  to  give  a 
resume  of  the  debate,  acknowledged  the  existence  of  diseases  of 
the  uterus  where,  although  the  symptoms  of  phlegmasia  might  be 
present,  there  is  actually  no  inflammation.  He  did  not  specify 
the  state  of  the  circulation  under  these  circumstances;  he  thought 
uterine  complaints  are  often  connected  with  the  general  system, 
but  nevertheless  are  frequently  primary  and  very  universally  con- 
nected with  catarrh,  i,  e.,  with  inflammation  of  the  lining  mem- 
brane of  the  cervix  or  body  of  the  uterus ;  sometimes  with  a 
granular  condition — that  these  granulations  are  of  little  import- 
ance, not  disturbing  the  general  system,  and  may  often  be  dissi- 
pated, and  yet  the  general  and  local  symptoms  may  continue.  He 
stated  also  that  deviations  of  the  uterus  have  but  little  effect  upon 
the  catarrh  of  the  mucous  membrane ;  that  this  more  frequently 
arises  from  other  local  causes,  such  as  abortions,  labors,  menstrual 
efforts,  etc.  The  treatment,  therefore,  of  all  these  cases  must  be 
greatly  modified,  trusting  both  to  general  and  local  measures, 
according  to  circumstances;  occasionally  he  deemed  caustics  were 
useful  to  stimulate  the  cervix  uteri  to  more  activity,  and  thus  favor 
resolution. 


CONGESTION".  41 

It  is  manifest  from  this  learned  debate,  although  M.  Eecamier 
and  others  intimated  that  there  was  an  engorgement  analogous  to 
those  of  erectile  tissues,  yet  that  there  was  no  positive  distinction 
drawn  between  this  variety  and  that  connected  with  inflamma- 
tion ;  all  seemed  either  to  confound  them  absolutely,  as  M.  Velpeau, 
or  to  acknowledge  that  the  erectile  congestion  was  merely  pre- 
liminary to  inflammatory  engorgement,  and  this  even  might  be 
the  cause  of  malignant  degeneracy.  Hence,  their  treatment  was 
founded  almost  exclusively  on  the  idea  of  local  inflammation  of 
a  chronic  character — hence,  the  importance  attached  to  leeches, 
revulsives,  mild  and  severe  caustics. 

Dr.  Lever,  although  he  defines  engorgement  to  be  a  swelling 
from  a  varicose  enlargement  of  the  bloodvessels,  yet  insists  that 
this  enlargement  is  the  result  of  chronic  inflammation ;  hence,  he 
recommends  antiphlogistics. 

M.  Duparcque,  in  his  very  scientific  work  on  the  "Diseases  of 
Women,"  dwells  much  upon  "  engorgements" — the  French  word 
for  "  congestion,"  but  evidently  believes  that  what  he  terms 
simple  engorgement  will,  if  persistent,  be  productive  of  all  the 
variety  of  organic  irritations. 

He  aptly  illustrates  the  simple  engorgement  as  appearing  in 
healthy  individuals  by  reference  to  the  mammary  gland  during 
lactation,  and  the  uterus  during  its  menstrual  state,  and  also 
during  pregnancy.     These  are  fit  illustrations. 

It  is  a  fact  well  known  that  in  all  these  physiological  conges- 
tions there  is  an  engorgement,  not  merely  of  the  small,  but  also 
of  the  large  bloodvessels — the  vasa  afferentia  and  the  vasa  effe- 
rentia,  as  seen  in  pregnancy,  etc.  There  is  strictly  no  infiltration 
of  the  tissues,  as  this  word  is  usually  understood.  There  is  no 
doubt  an  increased  quantity  of  interstitial  moisture,  which,  how- 
ever, is  hardly  perceptible  even  after  congestion  has  entirely 
subsided ;  but  as  to  positive  oedema  or  areolar  infiltration,  it  is 
not  usually  to  be  met  with. 

Analogous  opinions  may  be  quoted  from  Churchill,  Scanzoni, 
Colombat,  etc.,  all  of  whom  acknowledge  the  existence  of  san- 
guine congestions,  independently  of  inflammatory  action,  but 
very  generally  as  resulting  from  phlogosis,  but  still  more  fre- 
quently as  a  mere  preliminary  stage  to  inflammation:  all  there- 
fore drawing  no  real  distinction,  as  we  have  endeavored  to  do  in 


42  INTRODUCTION". 

the  text,  between  simple  or  nervous  congestion,  and  inflammatory 
or  organic  congestion. 

There  are  few  pathological  facts  with  which  we  are  more 
familiar  than  that  effusions  are  the  results  of  local  plethora. 
The  physiological  prototype  of  secretion  following  the  determina- 
tion of  blood  to  a  part,  as  observed  in  lachrymation,  lactation, 
etc.,  is  repeated  in  those  increased  secretions  and  hemorrhages  which 
result  from  a  morbid  accumulation  of  fluids  in  a  part.  Thus, 
serous  and  bloody  effusions  result  from  congestions  of  the  mucous 
membranes  of  the  nose,  of  the  lungs,  stomach,  bowels,  etc.,  and 
are  also  the  consequence  of  inordinate  morbid  determinations  of 
blood  to  the  brain,  spinal  marrow,  to  the  cavities  of  the  chest, 
abdomen,  etc. 

As  no  organ  of  the  body  is  more  liable  to  congestion  than  the 
uterus,  owing  to  its  great  vascularity,  and  its  being  the  subject 
of  ovarian  and  menstrual  excitements,  so  no  organ  is  more  prone 
to  unusual  discharges  from  its  mucous  membrane.  All  this  will  be 
readily  admitted,  but,  as  will  be  seen,  very  diverse,  and,  as  we 
should  regard  them,  very  singular  opinions,  are  entertained  upon 
this  subject.  Thus,  for  example,  the  discharges  from  the  uterus 
are  by  many  regarded  not  as  the  result,  but  as  the  cause  of  con- 
gestions, not  only  of  a  simple  active  determination  of  blood  to 
a  part,  but  even  as  exciting  positive  inflammation.  Moreover, 
these  increased  discharges  are  frequently  spoken  of  as  resulting 
not  at  all  from  local  irritations  or  excitements,  but  as  dependent 
entirely  upon  states  of  the  general  system — such  as  plethora  on 
the  one  hand,  or  anajmia  and  exhaustion  on  the  other,  or  from 
sudden  mal-conditions  of  the  blood.  Thus,  Dr.  Churchill  ob- 
serves that  menorrhagia  is,  inter  alia,  a  common  cause  of  con- 
gestion of  the  neck  of  the  uterus,  sometimes  even  of  inflamma- 
tion and  ulceration.  The  menses,  he  says,  is  a  secretion,  and  not 
a  hemorrhage ;  therefore,  in  the  first  degree,  we  have  increased 
discharge  of  the  menses,  without  any  alteration  of  the  uterus ; 
even  in  the  second  stage,  says  Dr.  Churchill,  where  pure  blood 
is  mingled  with  the  menses,  and  clots  appear,  there  may  be  no 
alteration ;  occasionally  there  is  some  erosion  of  the  mucous 
membrane.  In  the  third  stage  there  is  decided  inflammation, 
and  the  discharge  hemorrhagic,  clots  being  abundant.  M.  Du- 
parcque,  who,  as  we  have  seen,  dwells  much  upon  soft  engorge- 
ments of  the  uterus  in  its  different  degrees  or  stages,  speaks  of 


MENORRHAGIA.  43 

the  discharges  as  being  very  often  sanguine  and  profuse,  and 
that,  in  some  instances,  some  effusions  occur  in  the  proper  tissues 
of  the  cervix,  yet  the  same  congestions,  he  says,  may  result  from 
inflammations,  indurations,  malignant  disease,  etc.  M.  Scanzoni, 
who  makes  no  distinction  between  congestion  and  inflammation, 
insists  that  menorrhagia  is  often  the  consequence  of  uterine 
engorgement  whether  active  or  passive,  but  believes  that  it  often 
arises  from  the  state  of  the  system,  whether  plethoric  or  angemic, 
and  also  from  congestions  of  the  abdominal  viscera,  etc. 

Dr.  West,  whose  authority  upon  these  subjects  is  deservedly 
exceedingly  great,  seems  to  pass  by  with  little  attention  the 
whole  subject  of  congestion  and  of  hypertrophy,  as  being  in- 
volved essentially  in  the  nature  and  treatment  of  inflammation, 
although  he  does  allude  to  the  hypertrophy  of  the  uterus  during 
and  after  pregnane}^,  and  of  course,  also,  to  the  existence  of 
hypertrophy  where  there  is  a  polypus  in  the  uterine  cavity.  He 
treats  of  menorrhagia  as  arising  from  many  causes,  but  does  not 
point  out  the  pathological  condition  under  their  influences;  so 
that  the  inference  must  be  made  that  the  same  general  condition 
of  the  organ  is  always  present.  Hence,  he  speaks  of  all  the 
variety  of  local  diseases  of  the  uterus,  which  of  course  includes 
inflammations,  ulcerations,  tumors,  cancers,  etc.,  as  giving  rise 
to  menorrhagia,  but  almost  in  the  same  paragraph  alludes  to 
excitements  from  mental  or  from  moral  causes,  from  states  of  the 
ovaries,  from  displacements  of  the  uterus,  also  increased  secre- 
tions from  this  organ.  This  is  doubtless  true,  but  certainly  there 
must  exist  a  strong  pathological  distinction  in  the  kind  of  en- 
gorgement, which  arises  from  displacements,  from  mental  excite- 
ments, or  the  passions,  and  those  dependent  upon  local  organic 
disease. 

Dr.  Graily  Hewitt  observes  that  menorrhagia  is  often  the  result 
of  states  of  the  general  system,  such  as  those  produced  by  eruptive 
diseases.  He  thinks,  also,  it  may  arise  from  debility,  from  various 
states  of  the  blood,  as  observed  in  albuminuria,  etc.  These,  he 
thinks,  may  ensue  without  any  local  disorders;  and  when  local 
irritation  exists,  it  is  often  without  inflammation,  as  in  cases  of 
displacements.  Still,  he  speaks  of  profuse  menorrhagia  as  often 
the  beginning  of  serious  disease,  instead  of  regarding  it  as  a  pal- 
liative of  a  local  congestion.  Dr.  Hewitt  also  alludes  to  certain 
irregularities  in  menstruation  not  to  be  accounted  for  by  inflam- 


44  INTRODUCTION. 

mation  or  other  organic  lesions.  Now,  in  all  these  cases,  there 
must  be,  however  obscure,  some  reason  or  cause  why  the  san- 
guineous discharge  should  come  from  the  uterus.  There  must 
be,  as  in  cases  of  apoplexy,  a  cause  why  there  should  be  a  deter- 
mination of  blood  to  a  part,  and  hence  its  effusion ;  the  one  must 
precede  the  other.  If,  therefore,  it  be  granted  that  there  is  no 
inflammation,  all  that  we  contend  for  is  acknowledged,  namely, 
that  a  distinction  should  be  drawn  theoretically  and  practically 
between  those  congestions  and  discharges  the  result  of  phlogosis, 
and  those  where  no  such  morbid  action  exists. 

Dr.  Ashwell  speaks  of  menorrhagia  as  a  consequence  of  con- 
gestion, and  evidently  disconnects  the  idea  of  congestion,  in  a 
very  large  number  of  cases,  from  any  variety  of  organic  disease. 
Regarding  the  menses  as  a  secretion,  he  considers  the  first  variety 
of  menorrhagia  as  a  mere  increase  of  the  natural  flow ;  the  second 
variety  as  being  accompanied  with  blood — hence  more  or  less 
hemorrhagia.  But  both  these  varieties  may  appear,  and  in 
chronic  cases  may  continue  for  years,  without  any  organic  dis- 
ease. This  is  frequently  the  case  during  the  climacteric  period. 
He  alludes  to  causes  depending  upon  the  general  system,  par- 
ticularly to  states  of  plethora  or  of  anaemia.  In  these  last  cases 
the  discharge  is  termed  "  passive"  or  "  chronic."  In  the  treatment 
of  menorrhagia  he  depends,  in  the  plethoric,  upon  bleeding,  rest, 
cold,  and  astringents ;  these  last,  however,  are  not  to  be  employed 
during  the  first  few  days.  In  the  chronic,  he  treats  his  patients 
by  local  astringents,  good  diet,  and  tonics. 

In  all  this  theory  and  practice,  therefore,  Dr.  Ashwell  does  not, 
as  a  general  rule,  sustain  the  idea  that  there  is  local  disease,  or  even 
local  irritation.  Of  course,  he  does  not  explain  why  menorrhagia 
should  be  present ;  for,  certainly,  the  mere  existence  of  a  state  of 
plethora  or  ancemia  is  not  a  sufficient  cause  for  uterine  discharges, 
unless  there  be  some  additional  irritation  or  excitement  of  the 
uterus  itself.  Neither  does  he  present  us  with  any  distinctive 
marks  of  that  irritation  which  causes  congestion,  and  that  which 
excites  inflammation ;  yet  his  experience  would  indicate  that 
such  distinctions  ought  to  be  drawn,  inasmuch  as  he  states  that 
menorrhagia  may  come,  may  be  protracted  for  a  long  series  of 
months  or  years,  and  finally  disappear  without  any  local  organic 
disease,  leaving  the  organ  in  a  state  of  integrity. 

M.  Colombat  also  acknowledges  the  existence  not  only  of  the 


MENORRHAGIA.  45 

acute,  but  the  chronic  form  of  menorrhagia,  or  hemorrhagia  of 
the  uterus ;  they  ofteu  depend  on  some  peculiar  states  of  the  gene- 
ral system  intimately  associated,  doubtless,  with  the  menstrual 
nisus ;  also  in  the  chronic  forms,  which  he  terms  passive,  con- 
nected with  general  debility,  arising  especially  from  luxurious 
habits  of  living,  or  sometimes  from  poverty  and  distress.  Dr. 
Dewees,  another  advocate  for  the  menses  being  a  secretion,  and 
of  the  importance  of  drawing  a  distinction  between  menorrhagia 
and  hsemorrhagia  of  the  uterus,  intimates  his  belief  in  a  kind  of 
passive  hemorrhage  resulting  from  states  of  the  general  system, 
apparently  without  irritation. 

Professor  Byford,  although  a  great  advocate  for  the  existence 
of  local  inflammation  as  a  cause  of  menorrhagia,  demanding 
antiphlogistics,  caustics,  etc.,  yet  acknowledges  the  existence  of 
menorrhagia  in  certain  states  of  anaemia,  and  deterioration  of  the 
circulating  fluids,  without  intimating  the  existence  of  any  local 
inflammation.  He  also  states  that  menorrhagia  may  arise  from 
uterine  tumors,  from  irritation  of  the  ovaries,  or  of  hasmorrhoidal 
tumors.  He  does  not  inform  us  what  is  the  condition  of  the 
uterus  where  the  discharge  arises  from  ovarian  or  hasmorrhoidal 
affections.  In  such  cases  the  inference  is  fair  that  there  must  be 
congestions  of  the  uterus  without  inflammation  in  any  of  its  tis- 
sues; but  theoretically  and  practically  he  admits  of  only  one 
kind  of  congestion,  namely,  inflammatory. 

Dr.  Tilt,  who  considers  menstruation  as  the  result  of  ovarian 
excitement,  gives  some  excellent  directions  as  to  the  management 
of  young  women  after  puberty.  He  alludes  to  the  irregular  dis- 
charges which  are  then  often  observed,  sometimes  too  prolonged, 
sometimes  recurring  too  frequently,  and  yet  all  demanding  only 
a  little  negative  treatment — such  as  rest,  quietude  of  mind  and 
body.  Such  irregularities,  he  says,  are  usually  observed  in 
nervous  and  irritable  girls ;  the  discharge  increases  this  irrita- 
bility, of  which  it  is  therefore  the  effect  as  well  as  the  cause. 
He  says  the  constitution  may  be  undermined  by  this  discharge. 
All  this,  we  think,  is  perfectly  true;  yet  in  such  cases  Dr.  Tilt 
employs  the  word  "  irritability"  without  alluding  to  any  inflam- 
mation of  the  uterus  as  the  cause  of  these  complaints ;  while,  in 
another  paragraph,  he  affirms  that  ovaritis  is  the  real  root  of 
these  irregular  discharges  of  the  uterus;  morbid  menstruation 
being  the  evidence  of  ovaritis.     Inflammation  is  the  "  keystone 


46  INTRODUCTION. 

of  ovarian  pathology,"  and  altliougli  he  says  that  there  may  be 
other  agencies,  yet  this  is  the  grand  one  for  the  disorders  of 
menstruation;  amenorrhoea,  menorrhagia,  leucorrhoea,  being  bat 
the  symptoms  of  ovaritis,  or,  it  may  be,  other  pathological 
states.  Ovaritis,  he  says,  will  produce  hysteria;  but  hysteria 
will  not  produce  ovaritis,  as  supposed  by  Dr.  Copland,  and  yet 
he  affirms  that  mental  and  moral  disturbances  may  excite  inflam- 
mation of  the  ovary. 

Now,  whatever  degree  of  truth  there  may  be  in  these  opinions  of 
T)r.  Tilt  as  to  the  connection  of  morbid  menstruation  with  ova- 
ritis, yet  here,  as  in  other  places,  there  is  a  tacit  acknowledgment 
of  uterine  irritation  with  an  increased  discharge  arising  from 
mental  and  moral  causes,  with  or  without  ovaritis,  without  any 
metritis  in  any  of  its  forms. 

We  have  endeavored  to  maintain  that  increased  discharges  of 
mucus  and  serum  from  the  genital  organs  are,  perhaps,  in  a 
majority  of  cases,  the  result  of  active  congestion  without  inflam- 
matory action,  to  which  they  have  been  generally  referred  by 
authors.  Moreover,  that  these  discharges,  whether  white  or  red, 
are  not  the  result  of  debility  or  of  exhaustion,  but,  even  when 
intimately  associated  with  general  disorders  of  the  system,  are 
caused  and  kept  up  by  local  irritation,  preceded  or  accompanied 
by  a  certain  degree  of  congestion.  Authorities  are  very  gene- 
rally opposed  to  these  sentiments. 

By  recurring  to  what  has  been  already  said  of  the  debate  in 
1849,  in  the  French  Academy  of  Medicine,  it  will  be  seen  that 
however  different  might  be  the  sentiments  of  the  members  of  the 
Society,  they  almost  universally  put  confidence  in  local  antiphlo- 
gistics  for  the  relief  of  discharges  consequent  upon  engorgement, 
and  very  generally  resorted  to  even  actual  or  potential  caustics.  M. 
Baud  contended  that  the  general  system  was  almost  exclusively 
in  fault,  and  that  the  local  aftection  was  secondary.  He  there- 
fore trusted  to  general  remedies,  using  local  astringents,  etc.,  as 
adjuvants.  Other  speakers  contended  that  although  it  was  true- 
that  much  depended  upon  the  patient's  general  health,  yet  that 
local  afl'ections  were  very  often  present,  demanding  astringents, 
caustics,  etc.  Even  M.  Dubois  seems  to  have  formed  no  idea  of 
getting  rid  of  local  discharges  without  the  assistance  of  topical 
medicaments,  often  including  caustics.  Some  few,  as  Ilervez  de 
ChtJgoin  and  Dubois,  intimated  that  in  some  cases  displacement 


LEUCORRHCEA.  47 

was  the  immediate  cause  of  engorgement  and  discharges;  but 
others,  while  admitting  the  dispLacement,  insisted  on  the  necessity 
of  local  antiphlogistics;  and  M.  Velpeau  decidedly  asserted  that 
no  attention  should  be  paid  to  the  displacement  by  means  of 
pessaries,  etc. 

Dr.  Churchill  alludes  to  a  general  opinion- that  leucorrhoea  is 
the  result  of  debility,  but  intimates  that  there  must  be  some 
local  disturbance  superadded ;  still  he  thinks  local  remedies  in 
simple  uterine  leucorrhoea  not  advisable,  trusting  to  tonics,  balsam 
copaiba,  secale  cornutum,  muriate  and  other  preparations  of 
iron,  and  deprecating  injections  into  the  cavity  of  the  uterus 
as  dangerous.  He  quotes  Tyler  Smith  as  representing  that  these 
simple  uterine  discharges  consist  of  mucous  corpuscles,  oil  glo- 
bules, and  epithelial  scales,  entangled  in  the  viscid  alkaline 
plasma  coming  from  the  glands  of  the  neck ;  its  character  may 
vary,  and  occasionally  become  irritating. 

Dr.  Graily  Hewitt,  although  believing  in  the  frequency  of 
local  causes  of  leucorrha3a,  refers  many  cases  to  genei^al  states  of 
the  system,  such  as  plethora,  anosmia,  debility,  some  affections  of 
the  chest,  valvular  disease  of  the  heart,  etc.  Hence,  in  the  treat- 
ment he  depends  much  on  constitutional  remedies,  including 
ergot,  where  there  is  much  congestion  of  the  uterus,  copaiba, 
cubebs,  etc.  Among  the  local  causes,  he  of  course  includes  in- 
flammation, speaks  of  chronic  congestion  without  specifying  its 
nature  as  causing  leucorrhoea,  and  also  of  sympathetic  causes,  the 
uterus  itself  being  irritated  without  evidence  of  inflammation. 
This  we  believe  often  to  be  the  case,  and  also  that  such  irritations 
result,  as  Dr.  Hewitt  allows,  from  displacements. 

M.  Scanzoni  terms  leucorrhoea  an  uterine  catarrh,  which  at 
once  indicates  his  view  of  its  pathology.  The  nature,  therefore, 
of  the  discharge  depends  upon  inflammation,  whether  acute  or 
chronic;  and  also  upon  its  character,  including,  according  to  M. 
Scanzoni,  all  the  varied  discharges  in  the  different  morbific  states 
of  the  uterus,  and  also  malignant  diseases. 

Dr.  Ash  well  is  among  the  few  who  speak  of  leucorrhoea  as 
existing  without  inflammation  or  any  organic  lesion,  or  even,  in 
some  cases,  without  morbid  states  of  the  system.  (TLIe  speaks  of 
leucorrhoea,  acute  or  chronic,  where  the  natural  discharges  arc 
simply  increased,  as  being  cliiefly  mucous  or  seroid,  thick  and 
tenacious  when  cominjr  from  the  cervix  uteri,  thinner  when  from 


48  INTRODUCTION. 

the  uterus,  and  again  more  viscid  when  from  the  orifice  of  the 
vagina.  Leucorrhoea  he  regards  as  acute  or  cl^ronic,  speaks  of  the 
chronic  as  causing  great  relaxation  of  the  tissues,  displacement  of 
the  uterus,  and  also  inflammations  of  the  cervix.  Some  of  these 
chronic  conditions  he  terms  "  passive,"  as  dependent  upon  habit, 
upon  debility,  etc.  He  speaks  also  of  symptomatic  leucorrhoea, 
partly  as  arising  from  morbid  states  of  the  uterus,  and  partly 
from  sympathy  with  other  tissues,  as  the  vagina,  rectum,  blad- 
der, ovaries,  etc.  He  joins  also  most  authorities  in  the  opinion 
that  debility  and  other  analogous  states  may  give  rise  to  leucor- 
rhoea. He  observes  that  the  inflammatory  forms  of  leucorrhoea 
are  not  very  common.  In  the  treatment  he  confines  his  antiphlo- 
gistic remedies  merely  to  the  inflammatory  cases,  treating  simple 
forms  of  leucorrhoea  by  rest,  cold  or  warm  douches  to  the  vagina, 
mild  astringents,  etc. 

M.  Colombat  defines  leucorrhoea  as  being  a  supersecretion  of 
sero-mucous  matters,  independently  of  any  specific  or  malignant 
disease.  He  declares  that  leucorrhoea  may  arise  from  mental  and 
moral  causes,  from  general  or  local  atony  ;  he  regards  it  as  a  kind 
of  catarrh  of  the  uterus,  the  result  of  subacute  or  chronic  inflam- 
mation of  the  membrane. 

Leucorrhoea  often  becomes  chronic,  and  sometimes,  says  M. 
Colombat,  is  interminable,  and  may  completely  break  down  the 
patient's  system,  mental,  moral,  and  physical.  This  declaration, 
which  is  by  no  means  peculiar  to  M.  Colombat,  has  always  ap- 
peared to  us  as  very  strange.  A  muco-serous  discharge,  often 
not  exceeding  half  an  ounce,  or  one  ounce  per  diem,  cannot,  by 
its  continuance,  produce  debility  and  exhaustion  of  the  vital 
powers.  "Who,  that  is  acquainted  with  the  diseases  of  women, 
but  has  met  with  many  cases,  where  large  quantities  of  fluids, 
mucous  and  serous,  and  also  menstrual  and  hemorrhagic,  and,  in 
other  cases,  immense  quantities  of  limpid  urine  from  the  bladder, 
have  continued  with  more  or  less  intermission  for  months,  not 
to  say  years,  and  yet  the  patient  maintaining  her  flesh,  and  even' 
her  strength?  Have  we. not  a  right  to  presume  that,  in  the 
case  of  leucorrhoea,  the  discharge  is  of  minor  importance,  that 
the  exhaustion  is  dependent  on  some  undetected  cause,  which 
maintains  the  irritability  and  congestion  of  the  uterus,  and  thus, 
assisted  by  the  confinement  and  antiphlogistic  treatment  to  which 


LEUCORRHCEA.  49 

tLe  patient  is  often  subjected,  is  tlie  real  source  of  all  her  mental 
and  bodily  sufferings  ? 

Dr.  Dewees  is  among  the  advocates  of  inflammation  as  the 
cause  of  leucorrhoea,  which  he  divides  into  three  stages,  all  of 
which  are  to  be  treated  by  antiphlogistic  remedies,  until  the  symp- 
toms are  moderated. 

While  enumerating  the  causes,  whether  direct  or  indirect,  he 
acknowledges  that  a  predisposition  to  leucorrhoea,  dependent  upon 
the  condition  of  the  patient's  general  system,  often  exists,  but 
some  local  excitement  in  addition  is  necessary.  Mere  debility, 
therefore,  or  nervous  or  vascular  disturbance,  would  not,  per  se, 
bring  on  the  complaint.  He  declares,  however,  that  mental  and 
moral  states  may  be  among  the  exciting  causes,  but  this  seems  to 
be  inconsistent  with  the  idea  of  local  inflammatory  irritation. 

Dr.  Tilt,  who,  as  we  have  seen,  traces  menorrhagia  to  ovaritis, 
presents  the  same  views  as  regards  the  pathology  of  leucorrhcea. 
Nevertheless,  he  admits  that  there  are  cases  of  both  menorrhagia 
and  leucorrhoea  where  there  is  no  inflammation  of  the  ovaries, 
and  even  when  ovaritis  exists  he  does  not  intimate  that  there  is 
necessarily  metritis  in  any  of  its  forms,  although  white  or  red 
discharges  may  be  profuse.  Thus  he  cites  leucorrhoeal  discharges 
as  often  observed  in  young  girls  at  puberty,  especially  as  pre- 
ceding and  following  regular  menstruation,  and  also  a  similar 
evacuation  connected  with  the  disappearance  of  the  menses. 

It  appears,  therefore,  from  the  citations,  that  although  the  gene- 
ral opinion  is  maintained  that  phlogosis  of  the  genital  passages 
is  the  cause  of  leucorrhoea,  yet,  even  amongst  some  of  the  strong- 
est advocates,  the  admission  is  made  that  leucorrhoea  may  exist 
without  inflammatory  action.  Dr.  Tyler  Smith,  who  some  fifteen 
years  ago  published  an  erudite  work  on  the  subject  of  leucorrhoea, 
takes  an  opposite  ground,  declaring  that  in  a  great  majority  of 
cases,  leucorrhoea  is  not  dependent  on  inflammation ;  thart  abra- 
sion and  ulceration  of  the  os  uteri  sometimes  observed,  a^re  not 
primary  but  secondary ;  not  the  cause  but  the  effect  of  leucor- 
rhoea ;  that  they  may  be  cured  and  yet  the  leucorrhoea  will  re- 
main or  return.  He  observes  that  it  is  the  whole  tenor  of  his 
work  to  show  that  leucorrhoea  is  not  the  result  of  inflammation 
in  most  cases ;  that  the  importance  and  frequency  of  ulceration 
and  abrasion  have  been  exceedingly  enhanced ;  that  the  so-called 
ulcerations  are  seldom  more  than  abrasions  of  the  epithelial 
4 


50  IXTRODUCTIOX, 

covering;  tbat  tlie  term  "epithelial  abrasion"  should  become  the 
substitute  for  ulceration.  He  does  not  however  carry  this  idea 
to  the  extreme  of  denying  the  existence  of  local  causes  in  excit- 
ing inflammation  in  the  cervix,  for  he  speaks  of  the  inflammation 
resulting  from  wounds,  laceration  during  labor,  pressure  from 
polypous  tumors  or  other  sources,  acid  secretions  from  the  vagina, 
excessive  or  impure  coitus,  etc.  etc.  Still,  the  general  truth  he 
maintains  that  there  is  a  separate  origin  for  leucorrhoea,  and  that 
the  discharge  is  usually  the  cause  of  the  phlogosis. 

While  Dr.  Smith  thus  maintains  that  leucorrhoea  is  a  primary 
and  not  a  secondary  disease,  he  is  not  so  clear  as  to  the  causes  or 
the  real  pathological  condition  of  the  uterus,  when  leucorrhoea 
exists.  Like  other  authors,  he  refers  this  complaint  to  general 
debility,  specifying  anosmia,  nervous  affections,  cachexia,  strumous 
diathesis  as  causes ;  but,  as  will  be  observed  in  oiir  text,  mere  de- 
bility or  even  relaxation,  unless  excessive,  does  not  give  rise  to 
secretion.  All  these  states  of  the  sj'^stem,  therefore,  are  but  pre- 
disposing causes ;  there  is  a  necessity  for  some  exciting  cause  di- 
recting to  the  uterus,  which  is  the  real  or  proximate  cause  of  the 
complaint.  Hence,  Dr.  Smith  approximates,  we  think,  nearer  to 
the  truth,  when  he  speaks  of  mental  and  sexual  excitements,  or 
of  ovarian,  rectal,  cystic,  or  vaginal  irritations  as  giving  rise  to 
leucorrhoea.  He  speaks  also  of  the  leucorrhoea  of  lactation, 
intimating  that  the  exhaustion  produced  by  long  nursing  is  a 
cause  of  the  leucorrhoea ;  but  of  this,  we  think,  there  is  no  evi- 
dence, for  he  adds  that  it  is  the  reflex  irritation  on  the  uterus, 
caused  by  mammary  excitement.  This  is  the  true  solution.  So 
also  we  can  understand  how  displacements  of  the  organ,  or  tumors 
of  the  uterus,  may  be  numbered  among  the  causes.  Simple  ple- 
thora, therefore,  of  the  general  system,  or  anemia,  or  debility  are 
not  of  themselves  sufficient. 

Neither  does  it  appear  what  specific  idea  Dr.  Smith  associates 
with  the  word  "  irritation,"  so  usually  regarded  as  the  commence- 
ment of,  if  not  identical  with  the  inflammatory  process ;  he  insists 
that  it  is  not  inflammation,  and  yet  gives  no  specification  of  the 
dift'erence  between  it  and  that  organic  irritation  which  constitutes 
phlogosis.  His  idea,  also,  of  the  irritating  character  of  the  dis- 
charges in.fluor  albus  can  hardly  be  maintained  upon  his  hypo- 
thesis. Although,  therefore,  we  perfectly  agree  with  Dr.  Smith 
that  in  a  large  majority  of  cases  there  is  no  inflammation,  yet  we 


HYPERTROPHY.  51 

cannot  conceive  of  a  discharge,  presupposing  more  or  less  con- 
gestion without,  in  all  cases,  there  being  some  prior  irritation, 
whether  arising  from  local  or  general  causes. 

Few  authors,  it  wo  aid  appear  from  these  statements,  entirely 
ignore  the  general  principle  that  increased  discharges  are  the  re- 
sult of  congestion  without  inflammatory  action.  Yet  both  in 
discussions  and  practice  this  principle  is  very  frequently  forgot- 
ten; as  when  menorrhagia  and  leucorrhoea  are  regarded  both 
theoretically  and  practically  as  arising  from  debility,  or  when 
they  are  spoken  of  as  their  cause  rather  than  the  effect  of  irrita- 
tion. In  the  text,  we  have  endeavored  to  show  that  irritation 
always  precedes  not  merely  the  discharge,  but  also  the  prior  con- 
gestion, even  in  cases  of  anaemia  and  cachexia,  always  excepting 
cases  of  passive  hemorrhages  etc.,  from  disintegrated  condition  of 
blood,  as  in  low  adynamic  fevers,  etc. 

The  word  hypertrophy  also  has  been  much  misused,  and  con- 
founded with  all  alterations  of  tissue  which  may  be  induced  by 
active  inflammation  or  other  organic  diseases.  It  should,  we 
think,  be  confined  to  its  etymological  signification,  "  an  increased 
growth,  or  development  of  tissues  without  material  change  in  their 
constituents."  The  physiological  prototype  is  perfectly  familiar 
to  all  in  the  uterus  during  gestation,  and  in  the  mammas  during 
gestation  and  lactation.  It  is  maintained  by  us  and  substantially 
by  many  authorities  that  hypertrophy  is  the  result  of  an  active 
congestion  without  inflammation  ;  many,  however,  deny  this. 

M.  Duparcque  draws  a  very  good  distinction  between  soft  and 
hard  engorgement.  Hypertrophy  or  soft  engorgement  can  hardly 
be  considered  a  pathological  state,  as  it  is  observed  in  pregnancy, 
not  merely  in  its  ordinary  condition,  but  sometimes  as  noticed  in 
extraordinary  development  of  a  part  or  the  whole  of  the  cervix 
uteri,  rendering  labor  tedious.  Fibrous  and  polypous  tumors  will 
also  produce  hypertrophy  of  the  whole  organ.  Nevertheless,  M. 
Duparcque  seems  to  believe  that  this  condition  may  excite  inflam- 
mation, and  thus  "  hard  engorgement,"  or  induration. 

Dr.  Tyler  Smith,  after  drawing,  in  his  excellent  monograph, 
strong  lines  of  distinction  as  to  the  irritations  which  result  in 
leucorrhoea  and  those  which  cause  inflammation,  does  not  distin- 
guish between  hypertrophy  and  induration  of  the  uterus,  describ- 
ing each  and  both  as  the  result  of  inflammation  of  the  mucous 
membrane  with  epithelial  abrasion  or  superficial  ulceration.     He 


52  INTRODUCTION. 

does,  however,  speak  of  hypertrophy  as  consisting,  in  some  cases, 
of  nothing  more  than  vascular  fulness  with  ceclema. 

M.  Scanzoni  also  confounds  these  two  pathological  conditions 
in  almost  all  his  statements,  yet  he  speaks  of  vascular  engorgement 
and  development  of  muscular  tissue,  as  not  a  proper  inflammation 
when  observed  in  tumors  of  the  uterus,  pregnane}^,  etc.  Under 
the  head  of  chronic  engorgement  he  evidently  includes  both 
varieties  of  hypertrophy  and  induration. 

Dr.  West  also  dwells  almost  exclusively  on  inflammatory  in- 
duration ;  hypertrophy  is  noticed  chiefly  as  a  physiological  con- 
dition. 

Dr.  Churchill  alludes  to  the  distinction  between  hypertrophy 
and  induration,  without  specifying  particular  circumstances  under 
which  morbid  nutrition  may  occur.  The  distinction  between  the 
two  is  that  the  tissues  in  one  are  comparatively  soft,  in  the  other 
that  they  are  hard.  Hypertrophy  of  the  uterus,  in  whole  or  in  part, 
is  sometimes  natural,  at  least,  not  apparently  the  result  of  any 
diseased  process.  It  is  more  frequently  observed  in  the  cervix 
uteri,  which,  in  some  very  rare  cases,  is  said  to  measure  two  or 
three  inches  in  length. 

Dr.  Graily  Hewitt  does  not  seem  to  notice  hypertrophy  as  a 
morbid  state ;  he  makes  some  remarks,  however,  upon  natural  or 
acquired  prolongation  of  the  neck  of  the  uterus,  sometimes  as  a 
whole,  occasionally  of  only  a  part,  especially  of  the  anterior  por- 
tion of  the  neck.  This  has  been  attributed  to  the  development 
of  mucous  follicles  in  the  form  of  cysts.  It  may  exist  above  the 
proper  vaginal  portion  of  the  cervix  :  hence,  says  Huguier,  it  may 
give  rise  to  prolapsus,  or  procidentia  uteri.  Hypertrophy  of  the 
uterus,  he  recognizes  in  cases  of  pregnancy,  and  also  in  cases  of 
polypi ;  but  he  seems  to  doubt  whether  the  uterus  can  enlarge  to 
any  degree  without  the  presence  of  some  foreign  body,  fie  speaks, 
however,  of  hypertrophy  of  the  neck  of  the  uterus,  either  as  con- 
genital or  acquired.  As  to  induration,  it  is  merely  alluded  to,  and. 
the  distinction  between  it  and  hypertrophy  is  not  detailed. 

Sir  James  Simpson  is  almost  as  indefinite  on  the  subject  of  hy- 
pertrophy, congestion,  and  induration  of  the  uterus  as  the  authori- 
ties already  quoted.  He  speaks,  however,  distinctly  of  a  hyper- 
trophy of  the  organ,  not  merely  as  occurring  in  cases  of  polypi 
or  pregnancy,  but  as  remaining  for  some  time  after  parturition, 
and  this  is,  he  says,  physiological.     But  in  some  cases  the  pro- 


HYPERTROPHY.  53 

cess  of  involution  is  retarded,  or,  it  may  be,  arrested,  when  it  may 
be  regarded  as  a  pathological  condition.  It  can  be  recognized 
by  its  weight  and  by  its  size;  this  last  can  best  be  ascertained  by 
means  of  the  sound.  This  defective  involution,  he  thinks,  arises 
from  various  causes,  as  rising  too  early  from  the  bed,  frequent 
miscarriages,  and  also  from  inflammation.  The  use  of  this  last 
word  would  intimate  that  a  general  hypertrophic  condition  of  the 
organ  is  the  result  of  metritis.  This  certainly  is  not  the  case,  for 
metritis  leaves  the  uterus  indurated,  from  the  effusion  of  plastic 
lymph.  Still,  it  is  true  that  a  moderate  degree  of  inflammation 
about  the  cervix  or  os  uteri  or  even  in  the  adjacent  organs, 
may  be  the  cause  of  hypertrophy  of  the  body  of  the  uterus  :  this 
is  sympathetic,  and  doubtless  we  often  have  an  indurated  neck 
from  inflammation,  while  the  rest  of  the  organ  is  simply  hyper- 
trophied. 

He  mentions  as  the  result  of  this  deficient  involution  some 
pelvic  uneasiness  and  disturbance,  and  especially  also  displace- 
ments of  the  organ.  In  the  treatment.  Sir  James  seems  to  be 
guided  entirely  by  the  idea  of  inflammation,  for  he  recommends 
antiphlogistics,  e.  g.,  rest,  depletion,  revulsion,  etc. ;  afterwards  the 
iodides,  bromides,  etc.,  especially  the  bromide  of  potassium,  which, 
he  thinks,  promotes  absorption,  and,  at  the  same  time,  is  a  good 
tonic  and  sedative  on  the  reproductive  organs. 

In  obstinate  circumstances,  he  would  increase  the  hypertrophy 
by  the  use  of  sponge  tents  and  intra-uterine  pessaries ;  and  then 
employ  alteratives  under  the  idea  that  absorption  takes  place 
more  rapidly  after  excitement.  It  is  difficult  for  ordinary  minds 
to  understand  how  hypertrophy,  a  result  of  inflammation,  can 
either  directly  or  indirectly  be  improved  by  sponge  tents  or 
intra-uterine  pessaries,  which  confessedly  aggravate  a  hypertro- 
phied  condition ;  or,  how  it  is  that  alteratives,  which  are  not  suc- 
cessful when  the  uterus  is  moderately  enlarged,  can  become  more 
efficient  when  the  enlargement  is  much  greater  and  some  inflam- 
matory action  superadded,  by  the  mechanical  violence  excited  by 
these  foreign  bodies.  It  has  always  been  a  maxim  that  the  re- 
moval, not  the  increase,  of  irritation  was  essential  for  the  resolu- 
tion of  engorged  tissues. 

M.  Colombat,  in  his  learned  Treatise,  describes  cases  of  engorge- 
ment of  the  uterus  without  induration,  and  follows  Lisfranc  in 
terming  it  "  morbid  hypertrophy."     He  evidently  regards  it  as 


54  INTRODUCTION. 

similar  to  development  of  the  uterus  during  pregnancy,  and  at 
the  same  time  differing  from  engorgement  with  induration,  the 
result  of  inflammatory  action.  The  uterus  is  enlarged  generally, 
not  in  spots,  sometimes  as  much  as  at  the  third  or  fourth  month 
of  pregnancy  ;  its  tissues  soft  and  elastic  :  hypertrophy  is  some- 
times confined  to  the  cervix  uteri. 

Although  M.  Colombat  thus  points  out  the  peculiarities  of  hyper- 
trophy, yet  he  does  not  recognize  the  different  kinds  of  active 
congestion,  and  evidently  regards  this  state,  practically,  if  not 
theoretically,  as  one  of  chronic  metritis.  Hence,  his  treatment  is 
purely  antiphlogistic  ;  by  rest,  bleedings,  leeches,  cups,  revulsives, 
even  by  setons  and  issues.  He  also  alludes  to  inflammation 
being  often  present  demanding  the  local  application  of  astringents, 
caustics,  including  the  acid  nitrate  of  mercury.  No  allusion  is 
made  to  the  causes  of  the  hypertrophy,  and  therefore  nothing  is 
said  of  the  necessity  of  removing  the  causes  as  a  primary  and 
essential  part  of  the  treatment,  which,  if  removed  or  palliated, 
would  immensely  lighten  the  sufferings  of  the  patient,  rid  her  of 
the  necessity  of  being  confined  to  the  bed  for  three  or  four 
months,  and  thus  deliver  her  from  the  exhaustion  arising  from 
evacuating  remedies,  from  confinement  to  close  apartments,  and 
the  painful  and  debilitating  effects  of  severe  counter-irritants;  all 
of  which  indirectly  contribute  to  the  increase  of  the  general 
irritability  and  nervousness  of  the  system ;  mind  and  body  are 
alike  depressed. 

M.  Colombat  also  recognizes  the  fact  that  sometimes  there  is 
great  sanguine  engorgement  in  these  cases  of  hypertrophy  with- 
out induration.  This  engorgement  is  often  followed  by  profuse 
bloody  effusions,  and  this  frequently  without  much  relief;  still  the 
idea  is  held  out,  that  this  is  but  the  prodrome  of  many  organic 
diseases ;  thus  indicating  his  opinion  that  there  is  but  one  kind 
of  active  congestion.  Here,  too,  notwithstanding  the  hemorrhages, 
he  recommends  the  same  antiphlogistic  treatment  as  in  cases  of 
hypertrophy ;  still  he  declares  that  there  is  an  atonic  state,  which 
would  imply,  we  think,  something  different  from  inflammation, 
for  which  he  recommends  the  secale  cornutum,  astringents, 
cold,  etc. 

Perhaps  the  most  decided  testimony  we  have  seen  in  favor  of 
hypertrophy  of  the  uterus,  in  opposition  to  the  idea  that  it  is 
connected  with  chronic  inflammation,  is  given  by  M.  Klob  in  his 


HYPERTROPHY.  00 

Pathological  Anatomy  of  the  Female  Organs,  as  translated  by  Drs. 
Joseph  Kammerer  and  B.  F.  Dawson,  of  New  York.  M.  Klob 
insists  that  there  are,  on  various  occasions,  developments  of  the 
proper  interstitial  tissues  of  the  uterus,  causing  an  enlargement 
of  the  organ.  This  development  often  interests  the  muscular 
fibres,  sometimes  throughout  the  uterus,  sometimes  particular 
portions ;  but  more  frequently  it  is  the  connective  or  areolar 
tissue,  which  becomes  very  often  developed  in  all  parts  of  the 
uterus,  so  that  this  organ  is  enlarged,  not  unfrequently,  to  the  size 
of  a  fist,  the  body  assuming,  more  or  less,  a  globular  form.  This 
may  endure  for  a  shorter  or  longer  time,  and  may  be  "resolved" 
by  the  removal  of  the  cause  or  other  circumstances.  In  the  early 
stages  of  this  "  proliferation  of  connective  tissue"  the  fibres  are 
comparatively  soft  and  succulent ;  the  muscular  tissue  is  hyper- 
trophied,  and  the  bloodvessels  comparatively  large :  there  is  a 
state  of  hyperemia.  Subsequently  the  muscular  tissue  seems  to 
be  partially  lost  in  the  connective  tissue,  which  itself  becomes 
harder,  more  condensed,  and  the  bloodvessels  contracted.  After- 
wards, there  is  a  disposition  to  involution,  or  resolution,  the 
disease  not  increasing  beyond  a  certain  point,  and  the  tissues  may 
return  to  their  normal  state.  ' 

M.  Klob  says  that  this  state  is  the  result  of  habitual  hypersemia, 
and  he  cannot  regard  it  as  analogous  to  the  induration  resulting 
from  chronic  inflammation  of  the  parenchyma  of  the  organ :  with 
this  it  may  sometimes  be  complicated,  or  may  even  result  from 
inflammation  of  some  part  of  the  uterus  ;  inflammation  is  destruc- 
tive, but  "  proliferation"  is  not. 

Habitual  hypereemia,  according  to  Klob,  precedes  or  is  the 
proximate  cause  of  this  "formative  irritation."  This  congestion 
is  observed  after  repeated  and  rapid  deliveries,  where  there 
has  been  no  inflammation ;  also,  in  cases  of  displacements  of  the 
uterus,  from  fibrous  or  polypoid  tumors  of  the  uterus ;  also  when 
mucus,  pus,  menstrual  or  other  fluids  are  accumulated  in  the 
cavity  of  the  uterus  :  it  is  connected  also  with  "  various  tractions 
to  which  the  uterus  is  subject"  and  sometimes  in  consequence  of 
the  puerperal  condition.  M.  Klob  therefore  objects  to  the  use 
of  the  words  "infarctus"  and  "chronic  inflammation"  as  not  repre- 
senting the  true  pathological  condition  of  the  part. 

The  consequences  are  favorable.  M.  Klob  says  the  development 
is  generally  limited,  and  afterwards  there  is  a  disposition  to  invo- 


56  INTRODUCTION. 

lution,  observed  after  sources  of  irritation  are  removed  from  the 
uterus,  also  after  the  cUraacteric  period.  During  its  existence,  it 
often  interferes  with  the  menstrual  functions,  and  sterility  may 
be  a  result.  M.  Klob  also  deems  supposititious  the  idea  that  this 
"  proliferation  of  the  tissues"  has  any  connection  with  the  pro- 
duction of  cancer  either  of  the  uterus  or  of  other  organs  of  the 
body. 

These  observations  of  M.  Klob  are  very  much  in  unison  with 
those  taught  b}'-  the  author  for  many  years,  and  which  have  been 
recorded  in  the  text,  to  wit,  that  there  is  a  peculiar  irritation 
causing  hyperasmia  or  congestion  without  inflammation,  followed 
by  a  development  of  the  tissues  of  the  organ,  and,  therefore,  its 
enlargement.  Hence,  local  difficulties  from  pressure,  etc.,  and 
functional  disturbances  result  from  this  hypertrophic  condition. 

Dr.  Snow  Beck,  in  a  valuable  paper  read  before  the  Obstetrical 
Society  of  London,  Feb.  7,  1866,  not  merely  recognizes  distinctly 
the  essential  difference  between  hypertrophy  and  an  indurated 
condition  of  the  uterus,  but  refers  to  post-mortem  examinations 
and  also  to  microscopic  investigations  reported  by  himself  to  the 
London  Medical  Society  in  1851.  These  investigations  show  that 
the  enlargement  of  the  uterus  is  regular  or  pyriform ;  that  its 
cavity  is  dilated,  and  that  the  orifice  of  the  uterus  is  often  patu- 
lous, its  lips  occasionally  prolonged  and  swollen,  the  mucous 
membrane  turgid,  red,  and  often  said  to  be  ulcerated,  when  there 
is  actually  no  inflammation  and  no  ulceration.  The  sound  indi- 
cates that  the  length  of  the  organ  is  extended  from  three  to  six 
inches.  The  "pathological  condition  essentially  consists  in  an 
enlargement  of  the  muscular  tissue  of  the  uterus,  without  the 
presence  of  any  inflammatory  or  heterologous  deposits." 

These  states  are  the  result  generally  of  abortions,  premature  or 
natural  confinements,  and  according  to  Dr.  Beck  are  caused,  first, 
by  a  deficient  contraction  of  the  uterus  after  delivery,  and  second, 
by  the  partially  developed  state  of  the  uterus  in  abortion  which, 
was  unfavorable  for  the  changes  requisite  for  its  reduction  in  size. 

This  hypertrophy  of  the  uterus  may  exist  for  a  long  time,  even 
for  years,  without  much  inconvenience;  still,  however,  the  patient 
is  liable  to  attacks  of  monorrhagia,  without  any  apparent  cause. 
In  chronic  cases,  too,  "congestion"  of  the  enlarged  organ  or  "con- 
gestive inflammation"  may  be  induced,  followed  by  the  usual 
symptoms  of  local  disease.     Dr.  Beck  seems  to  believe  that  as  the 


METRITIS.  57 

orifice  of  the  uterus  is  open,  and  the  cavity  large,  that  pregnancy 
may  readily  occur,  and  this  event  was  most  favorable  to  a  return 
of  the  ors:an  to  its  natural  condition. 

Cases  of  this  kind  we  ourselves  have  met  with,  and  the  whole 
history  given  by  Dr.  Beck  confirms  the  idea  of  an  enlargement 
of  the  uterus,  i.  e.,  hypertrophy,  as  a  morbid  state,  productive  of 
irritation,  menorrhagia,  and  engorgements,  which  may  continue 
for  months  or  years  without  organic  changes,  such  as  inflamma- 
tion or  induration.  It  is  true,  however,  that  this  enlarged  state 
may  be  followed  by  various  displacements  of  the  organ,  and  also, 
not  from  its  own  nature,  but  from  accidental  causes,  local  inflam- 
mation may  be  superadded,  generally  in  the  cervix,  and  in  a  few 
instances  in  the  body  of  the  organ.  What  Dr.  Beck  understands 
by  the  word  "congestion,"  sometimes  caused  by  menorrhagia  or 
by  "congestive  inflammation,"  is  not  very  apparent,  as  inflamma- 
'sBlfo'h-  is  always  accompanied  by  congestion,  and  few  authors  recog- 
nize congestion  as  independent  of  inflammatory  action. 

Metritis. — We  have  thus  presented  a  short  summary  of  the  dis- 
crepancies, among  authors,  as  to  what  we  regard  the  non-inflam- 
matory affections  of  the  uterus.  There  can  be  no  doubt,  however, 
that  metritis  in  some  of  its  forms  not  unfrequently  exists,  some- 
times acute  and  frequently  chronic.  The  opinions,  as  to  the 
character  of  acute  metritis,  do  not  essentially  differ ;  they  are 
always  regarded  as  dangerous,  and  require  the  usual  antiphlogis- 
tic treatment  with  proper  attention  to  the  general  system. 

As  regards,  however,  chronic  metritis,  its  nature,  its  conse- 
quences, its  frequency,  and  especially  its  treatment,  and  the  diag- 
nosis between  it  and  other  forms  of  uterine  irritation,  there  has 
been  no  uniform  sentiment  in  the  profession.  The  whole  question 
is  as  open  for  investigation  and  for  decision  now,  as  it  has  been 
for  years  past,  notwithstanding  the  able  and  laborious  investiga- 
tions of  pathologists  and  practitioners.  What  then  is  the  "  role" 
which  inflammations  of  the  uterus,  and  especially  of  the  cervix 
uteri,  have  in  the  complaints  of  women  ? 

As  frequently  intimated,  the  weight  of  authority  is  in  favor  of 
the  dogma  that  the  nervous  and  neuralgic  complaints  of  women, 
their  aneemia,  chlorosis,  and  debility,  with  the  consequent  dis- 
turbance of  important  viscera  of  the  head,  thorax,  and  abdomen, 
are  all  the  result  of  chronic  inflammation,  with  or  without  ulcera- 
tion or  granulation  of  the  mucous  membrane  of  the  cervix  uteri. 


58  IXTRODUCTIOX. 

It  is  needless  to  detail  tlie  names  and  quotations  upon  this  point; 
tlie  declarations  of  Lisfranc  in  France  and  Bennett  in  England,  as 
to  the  frequency  and  importance  of  these  affections,  and  the 
necessity  of  persevering  in  antiphlogistic  measures,  and  often  in 
the  use  of  the  potential  and  actual  cautery,  are  too  well  known 
and  too  universally  followed  to  need  any  citations ;  we  will,  how- 
ever, quote  a  few  opinions  from  those  who  have  partially  at 
least,  if  not  entirely,  protested  against  this  pathology,  and  what 
seems  to  us  its  serious  and  dangerous  practical  consequences. 

Dr.  Tyler  Smith  is  very  explicit  in  his  opposition  to  the  phlo- 
gistic theory  of  uterine  affections.  We  have  already  quoted  at 
length  his  opinions  on  the  subject  of  congestion,  leucorrhcea, 
menorrhagia,  etc. ;  and  although  he  acknowledges,  as  every  one 
must  do,  the  occasional  existence  of  inflammation  and  epithe- 
lial abrasion  of  the  os  and  cervix,  yet  he  does  not  subscribe  to 
the  idea  of  their  frequency  or  even  their  importance,  as  they  are 
not  primary,  but  secondary;  the  result  generally  of  leucorrhcea, 
although  they  may  arise  sometimes  from  local  causes,  as  from 
wounds,  lacerations,  displacements,  etc. 

Therefore,  he  does  not  rely,  in  the  treatment  simply  upon 
antiphlogistic  measures.  The  original  or  primary  affection 
demands  chief  attention.  Hence,  constitutional  remedies  are  all 
important;  or,  specific  medicines,  taken  internally,  which  may 
have  a  peculiar  determination  to  the  pelvic  organs.  Should, 
however,  inflammation  or  epithelial  abrasion  exist,  then  of  course 
local  remedies  are  to  be  superadded.  In  the  treatment  of  these 
affections  and  also  of  hypertrophy  of  the  uterus,  he  depends  upon 
the  local  application  of  lunar  caustic;  he  condemns  most  empha- 
tically the  use  of  powerful  caustics,  and  gives  a  lamentable  list 
of  the  evil  consequences,  such  as  strictures  and  obstructions  of 
the  canal,  deformities  of  the  cervix,  preternatural  adhesions  to 
the  vagina,  destruction  of  portions  of  this  tube,  pelvic  abscesses, 
peritonitis,  and  not  unfrequently  death.  He  thinks  the  supposed 
good  effects  of  these  caustics  can  be  as  well  secured  without  any 
danger  by  the  nitrate  of  silver,  and  the  tincture  of  iodine. 

Considering  the  causes  of  leucorrhcea,  he  has  no  hesitation  in 
treating  displacement  of  the  organ  by  means  of  pessaries,  re- 
garding them  not  only  as  useful,  but  often  as  indispensable.  He 
depends  chiefly  on  soft  pessaries,  especially  sponges. 

Dr.  West  comes  to  very  nearly  the  same  practical  conclusions 


METRITIS.  59 

as  Dr.  Smith.  He  condemns  in  a  strong  manner  tlie  heroic  treat- 
ment by  caustics,  for  ulceration,  hypertrophy,  and  induration  of 
the  neck.  Nevertheless,  his  pathological  views  differ  materially 
from  those  of  Dr.  Smith.  Instead  of  regarding  leucorrhoea  and 
menorrhao;ia  as  existing^  without  inflammation,  he  seems  inclined 
to  the  belief  that  this  organic  irritation  is  the  real  source  of  most 
of  these  uterine  affections.  He  maintains,  however,  by  an  array 
of  facts,  that  the  inflammation  of  the  cervix  is  not  the  chief  source 
of  mischief,  but  that  the  seat  of  the  complaint  is  chiefly  in  the  uterine 
cavity.  He  declares  that  the  discharges  from  the  cervical  glands 
are  not  so  common  as  reported ;  indeed,  they  are  very  often  absent. 
He  opposes  himself  very  much  to  the  Bennett  school,  by  asserting 
that  abrasion  and  ulceration  of  the  mucous  membrane  of  the  os 
and  cervix  is  by  no  means  so  frequent  as  has  been  maintained ; 
and,  moreover,  that  when  present,  they  are  of  little  comparative 
importance.  He  states  facts  to  show  that  these  conditions  of  the 
tissue  may  exi^  without  any  induration  of  the  cervix;  and  the 
reverse,  that  induration  of  the  cervix  may  exist,  without  ulce- 
ration and  abrasion.  He  maintains,  also,  that  generally  the 
uterine  symptoms  vary  but  little,  whether  abrasion  be  present  or 
not — being  often  severe  when  they  are  absent,  and  not  much 
aggravated  if  they  should  exist.  Even  when  an  ulceration  is 
present,  it  never  appears  like  an  excavation,  as  in  other  parts  of 
the  body,  which,  we  think,  tantamount  to  saying,  that  it  is  not 
an  ulceration  at  all,  or,  in  the  language  of  Dr.  Lee,  "  it  has  no 
centre,  no  surface,  and  no  circumference ;"  it  is  merely  a  granular 
elevation,  a  development  of  the  natural  papillae  of  the  mucous 
membrane  during  inflammation,  without  loss  of  tissue,  and  there- 
fore no  ulcer ;  and  post-mortem  examinations  seldom  show  any 
vestiges  of  its  prior  existence. 

The  causes  of  this  chronic  inflammation  of  the  uterus  are 
various.  Dr.  West  refers  some  forty  or  fifty  per  cent,  to  the 
incidents  of  pregnancy,  abortion,  and  parturition;  many  to  the 
menstrual  nisus  and  congestion,  and  many  to  sexual  excitement 
and  its  inordinate  indulgence.  This  we  think  is  the  weak  part 
of  Dr.  West's  essay;  these  are,  it  is  true,  sources  of  irritation, 
but  Ave  perceive  no  evidence  that  such  irritations  ma}?-  not  often 
exist  for  days,  months,  and  years,  and  be  productive  of  severe 
symptoms  without  any  inflammatory  action.  Even  after  parturi- 
tion, it  is  seldom  true  that  the  arrest  of  the  natural  involution 


60  INTRODUCTIOX. 

of  tlie  uterus  is  owing  to  inflammation,  or  productive  of  this 
complaint;  provided,  of  course,  no  mechanical  injury  has  been 
sustained.  Sir  James  Simpson,  Dr.  Wright,  and  many  others, 
speak  of  this  involution  as  owing  to  a  deficiency  of  excitement 
or  debility,  so  that  there  is  an  actual  degeneration  of  the  tissues. 
Dr.  West  speaks  of  displacements  of  the  uterus  as  being  con- 
nected with  inflammation,  as  a  cause,  especially  in  its  acute  forms, 
and  in  many  chronic  cases.  Such  displacements  therefore  demand, 
he  thinks,  antiphlogistic  and  not  mechanical  remedies,  which 
last  he  condemns,  except  in  special  cases  of  great  relaxation,  pro- 
cidentia, etc. 

Dr.  West  infers  that  inflammation  and  ulceration  of  the  os  uteri 
are  not  indicative  of  uterine  symptoms  nor  of  its  progress ;  hence, 
remedies  for  this  ulceration  do  not  constitute  the  proper  thera- 
peutical course.  Moreover,  ulceration  of  the  os  has  no  particular 
influence  in  producing  abortion  or  causing  sterility. 

We  could  wish  that  the  numerous  advocates  fo,r  the  frequent 
existence  of  abrasions  and  ulcerations  of  the  os,  so  long  main- 
tained by  influential  authors,  and  leading  to  a  tedious,  painful, 
and  dangerous  practice,  would  study  the  work  of  Dr.  West,  that 
they  might  become  converts  to  some  of  his  conclusions. 

Dr.  Wright,  whose  work,  the  result  he  says  of  much  personal 
observation,  has  just  appeared,  is  very  decided  in  his  opposition 
to  the  modern  doctrines  of  inflammation  of  the  cervix  and  body 
of  the  uterus.  Of  course,  he  admits  their  existence,  but  not 
their  great  frequency  or  importance.  He  joins  with  Dr.  Aitken, 
in  maintaining  that  there  is  often  great  irritation  of  the  uterus 
and  injection  of  its  bloodvessels  where  there  is  no  proper  inflam- 
mation, and  yet  giving  rise  to  some  of  the  phenomena  of  inflam- 
mation. He  says  that  such  determinations  of  blood  are  often 
found  in  other  organs  of  the  -body,  often  transitory  and  produc- 
tive of  no  injury;  that  such  determination  to  the  uterus  should 
exist  is  therefore  supported  by  analogy,  and  Dr.  Wright's  expe- 
rience confirms  it. 

He  alludes  also  to  many  cases  of  enlargement  of  the  cervix  and 
body  of  the  uterus,  supposed  to  be  the  result  of  inflammation, 
but  really  attributable  to  fatty  degeneracy,  owing  to  a  deficiency 
of  renovating  power,  imperfect  nutrition,  dependent  generally  on 
systemic  debility. 

Dr.  Wright  also  believes  that  even  many  of  the  abrasions  and 


OVARITIS.  61 

granulations  observed  at  tbe  os  are  referable  to  deficient  nutrition, 
occurring  in  various  cachectic  conditions  of  the  system ;  or,  as 
often  the  case,  the  result  of  some  mechanical  irritation,  and  there- 
fore, strictly  speaking,  local,  not  involving  the  general  system. 
He  specifies  particularly  pressure  from  hardened  feces  in  the 
rectum,  and  the  necessity  arising  to  keep  the  bowels  in  a  relaxed 
condition  and  to  avoid  straining  at  stool.  Dr.  Wright,  in  accord- 
ance with  his  vicAvs,  seldom  resorts  to  powerful  remedies,  caustics, 
etc.,  preferring  even  a  solution  of  nitrate  of  silver  to  the  solid 
nitrate. 

Dr.  Tilt,  whom  we  have  already  quoted  as  a  non-believer  in 
irritable  uterus,  is  firmly  persuaded  that  most  uterine  affections 
are  dependent  upon  ovaritis;  the  inflammation  is  sometimes  con- 
fined to  a  vesicle,  but  more  frequently  it  involves  the  whole  organ 
and  adjacent  tissues.  He  believes  that  this  ovarian  inflammation 
is  often  the  result  of  mental  and  moral  causes,  of  sexual  passions, 
etc.  This  he  sometimes  terms  ovarian  irritation,  and  although  he 
believes  it  improper  for  females  to  be  married  who  have  ovaritis, 
yet,  he  acknowledges  that  in  a  state  of  ovarian  irritation  marriage 
may  be  useful.  This  is  certainly  a  very  nice  distinction,  and  no 
doubt  in  theory  has  much  truth  in  it ;  but  if  Dr.  Tilt's  views  be 
adopted,  who  will  draw  the  distinction  practically  between  this  irri- 
tation, and  inflammation  of  the  ovaries,  esj^ecially  as  it  is  evident, 
as  Dr.  Tilt  believes,  that  irritation  is  the  commencement  of  ovaritis. 
Hence,  any  aggravation  of  this  irritation  by  marriage  would,  of 
necessity,  be  injurious.  But  as  regards  the  uterus,  he  specifies 
amenorrhoea,  dysmenorrhoea,  and  menorrhagia  as  consequences 
of  ovaritis.  This  may  be  true,  but  what  then  is  the  pathological 
condition  of  the  uterus  itself?  Not  inflamed,  certainly;  but  still 
in  a  state  of  irritation,  when  pain  and  spasm  exist  in  dysmenor- 
rhoea and  profuse  evacuations  in  menorrhagia,  and  in  a  state  of 
atony,  the  directly  opposite  of  inflammation,  when  amenorrhoea 
is  present.  The  result,  therefore,  is  that  Dr.  Tilt  unwittingly 
acknowledges  a  condition  of  the  tissues  causing  various  serious 
disturbances  where  there  is  no  inflammation,  and  this  is  the  great 
point  for  which  we  are  contending.  This  reason  is  not  invalidated 
even  if  inflammation  of  the  cervix  should  occasionally  exist,  in- 
asmuch as  Dr.  T.  regards  such  cervicitis,  as  well  as  menorrhagia, 
as  ordinarily  resulting  from  ovaritis. 

Dr.  Tilt  gives  a  more  distinct  acknowledgment  of  this  state  of 


62  INTRODUCTION. 

irritation  when  he  affirms  there  is  a  great  deal  of  sensibility  about 
organs  where  there  is  no  "  apparent^''  disease,  and  that  such  sensi- 
bility remains  as  a  kind  of  ^'■reminiscence.''''  Moreover,  that  such 
sensibility  in  one  organ  often  depends  on  disease  in  another  ;  as 
affections  of  the  bladder  arising  from  disease  of  the  kidney  ;  those 
of  the  uterus  from  disease  of  the  ovary.  He  might  easily  have 
multiplied  indefinitely  these  illustrations,  as  almost  every  part  of 
the  body  may  occasionally  sympathize  with  a  diseased  organ : 
pain  in  the  head  from  disturbance  of  the  stomach:  irritable 
bladder  and  irritable  rectum  from  states  of  the  uterus  as  well  as 
of  the  ovaries ;  spinal  irritation,  disturbances  of  the  functions  of 
the  heart  and  lungs  involving  the  comfort,  it  may  be  the  life  of 
the  individual,  and  yet,  as  Dr.  Tilt  would  say,  without  any  appa- 
rent disease.  Certainly  the  deduction  must  be  made,  that  all  these 
are  morbid  conditions  often  of  a  severe  type,  where  there  is  no 
inflammation. 

The  experienced  Dr.  Graily  Hewitt  distinctly  announces  his 
belief  that  this  irritation  of  the  ovaries  is  not  inflammatory,  that 
it  is  a  state  of  hypercesthesia,  an  "  exaltation  of  nervous  sensation 
in  the  affected  parts,"  what  we  have  termed  nervous  irritation. 
It  is  the  result  of  various  exciting  causes,  but  especially  those 
connected  with  the  sexual  feelings ;  but  it  is  not  dependent,  as 
Bennett  and  others  would  insist,  upon  inflammations  of  the  uterus. 
Drs.  West  and  Negrier  entertain  the  same  opinions ;  the  latter 
has  designated  it  a  state  of  nervous  irritation  of  the  ovaries, 
by  the  word  "  ovarie,"  believing  that  it  is  intimately  associated 
with  the  phenomena  of  hysteria,  as  cause  or  effect. 

Dr.  Churchill  and  Dr.  Lay  cock  also  insist  on  this  condition  of 
the  ovaries,  where  there  is  no  evidence  from  swelling,  fever, 
abscess,  etc.,  of  inflammation  of  the  ovaries,  and  yet  all  these 
symptoms  are  directly  or  indirectly  connected  with  that  train  of 
phenomena,  termed  hysteria,  and  which  have  by  so  many  patholo- 
gists been  deemed  as  dependent  almost  universally  on  inflamma- 
tion of  the  uterus,  especially  of  the  cervix. 

If  to  these  authorities  be  added  the  names  of  Bernlitz  and 
others  who  refer  the  so-called  uterine  inflammation  to  peri-uterine 
inflammation,  to  cellulitis,  etc.,  there  can  be  no  doubt  that  the 
supposed  frequency  of  inflammation  of  the  neck  of  the  uterus 
and  the  urgent  necessity  of  treating  it  and  its  consequences  by 
heroic  remedies  cannot  be  maintained  without  great  reserve. 


PELVIC    CELLULITIS.  63 

The  latest  publication  on  Diseases  of  the  Uterus  is  by  Dr.  T. 
Gaillard  Thomas,  of  New  York,  who  has  obtained  a  high  reputa- 
tion, and  who  is  a  man  of  talent,  erudition,  and  dexterity.  We 
must  express  regret  that  he  has  so  fully  indorsed  the  principles 
and  practice  of  Dr.  Bennett,  more  or  less  in  opposition  to  those 
distinguished  authorities,  Drs.  Tyler  Smith,  Graily  Hewitt,  West, 
Lee,  Wright,  etc.,  whom  we  have  just  quoted.  His  views  are 
summed  up  in  the  following  declaration  :  "  Metritis  in  all  its  forms 
is  the  keystone  of  the  arch  on  which  rest  the  usefulness  and  know- 
ledge of  the  Gynecologist."  Professor  Byford,  of  Chicago,  has,  as 
we  have  seen,  indorsed  the  same  views  ;  hence,  in  the  East  and  the 
West  of  our  country,  these  doctrines  and  this  practice  are  pro- 
mulgated with  all  confidence  and  authority,  which  have  been  long 
tried  in  Europe,  and  have  been  found  wanting.  Their  influence 
is  on  the  wane,  if  we  can  credit  some  of  the  works  already 
mentioned,  and  also  the  opinion  of  a  distinguished  practitioner  of 
London,  who  states,  in  a  letter  to  the  author,  "I  do  not  wish 
you  to  infer  that  I  am  one  of  those  much  given  to  cauterizing 
the  cervix  of  the  uterus.  I  believe  that  hobby  has  been  greatly 
overridden." 

Let  it  be  remembered  also  that  the  practice  thus  recommended 
is  tedious,  painful,  dangerous,  and  often  fatal,  requiring  a  long 
confinement  without  fresh  air  and  exercise,  and  the  delightful 
stimulus  of  social  intercourse;  while  it  may  be  safely  asserted  on 
the  other  hand  that  there  is  no  peculiarity  in  such  inflammations, 
no  necessity  for  such  heroic  treatment,  but  that  a  practice  simple, 
without  danger,  and  almost  without  pain,  requiring  no  seclusion, 
is  equally  if  not  far  more  efiicient. 

This  is  not  the  place  to  criticize  the  opinions  and  practice  of 
Dr.  Thomas,  on  the  subject  of  metritis  or  endometritis,  even  if 
we  deemed  it  desirable ;  still,  this  question  as  to  the  frequency  and 
importance  of  these  affections,  and  as  to  their  proper  treatment, 
is,  at  the  present  day,  so  engrossing  that  we  venture  to  fix  atten- 
tion upon  one  or  two  points. 

He  recommends  in  the  management  of  cervical  endometritis — 
a  disease  which  is  acknowledged  not  to  be  of  a  dangerous  or  ma- 
lignant type — that  the  whole  cervix  uteri  should  be  dilated  impri- 
mis by  sponge  tents  or  sea  tangle,  especially  where  granulations 
exist.  The  object  of  this  severe  mechanical  pressure  upon  an 
inflamed  granular  surface  is  to  obtain  more  space  for  the  appli- 


.64  INTKODUCTION. 

cation  of  remedies.  These  remedies,  with  few  exceptions,  imply 
the  constant  resort  to  the  speculum,  with  all  its  inconveniences, 
so  that  they  may  be  applied  directly  to  the  inflamed  surface. 
These  medicinal  agents  include  nitrate  of  silver,  saturated  solu- 
tions of  copper,  lead,  or  zinc,  tannin,  and  also  chromic  acid. 
These  articles  are  sometimes  to  be  injected  into  the  cervical 
canal,  requiring,  at  least,  a  partial  introduction  of  a  hard  pipe 
into  this  inflamed  passage ;  or,  in  other  cases,  dossils  of  cotton, 
with  a  string  attached,  are  by  means  of  a  curette  to  be  deposited 
within  the  cervix  for  a  longer  or  shorter  time ;  or,  what  Dr. 
Thomas  now  prefers,  sponge  tents  loaded  with  some  of  these 
medical  agents,  and  then  deposited  in  the  canal. 

If  such  a  peculiar  combination  of  mechanical  and  chemical  irri- 
tants were  employed  in  the  treatment  of  inflammations  of  the 
mucous  membranes  of  the  eye,  the  ear,  the  nose,  the  rectum,  or 
the  urethra,  experienced  surgeons  would,  we  think,  be  exceed- 
ingly astonished:  and  why  inflammatory  affections  of  the  delicate 
mucous  membrane  of  the  cervix  should  require  sponge  tents  and 
suppositories,  tubes  and  curettes,  and  the  long  list  of  stimulating 
alterative  and  even  escharotic  applications,  cannot  certainly  be 
explained. 

The  same  treatment  is  boldly  extended  to  the  cavity  of  the  body 
of  the  uterus,  the  os  uteri  being  dilated  by  sponge  tents  ;  then,  by 
means  of  dossils  of  lint  or  cotton  tied  on  a  flat  probe,  the  mucous 
membrane  is  to  be  painted  with  a  solution  of  nitrate  of  silver, 
with  preparations  of  iodine,  or  even  with  chromic  acid.  Ointments 
containing  narcotics,  nitrate  of  silver,  or  acetate  of  lead  may  be 
introduced  within  the  cavity  by  suitable  instruments.  The  solid 
nitrate,  it  is  said,  rnay  be  applied,  although  with  the  declaration 
that  it  will  produce  severe  pain,  colic,  and  great  prostration,  and 
therefore  to  be  reserved  for  obstinate  cases.  Dr.  Thomas  even 
ventures  to  recommend  strong  injections  into  the  uterus,  although 
admitting  that  they  may  produce  severe  pain,  or  even  peritoneal 
inflammation  and  death.  This  is  in  opposition  to  the  advice  of  Dr. 
Churchill  and  also  of  Professor  Simpson,  who  cannot  be  accused 
of  timidity  or  reserve  in  the  employment  of  powerful  remedies. 

As  to  metritis.  Dr.  Thomas  alludes  to  its  frequent  existence, 
following  Bennett  in  the  idea  that  prolapsus,  anteversion,  and 
retroversion  are  often  the  result  of  localized  metritis.  This  is  in 
entire  opposition  to  the  current  testimony  of  the  profession.    Cervi- 


CORPOREAL    METRITIS.  65 

cal  metritis  is  not  very  uncommon,  but  chronic  corporeal  metritis 
is  regarded  as  a  rare  affection,  and  when  existent  is  very  seldom 
if  ever  confined  to  one  part  of  the  organ,  whether  anterior  or 
posterior. 

In  the  management  of  cervical  metritis,  the  ordinary  palliative 
and  soothing  treatment  not  readily  succeeding,  it  is  recommended 
to  blister  the  cervix  by  means  of  cantharides  in  collodion  or  ace- 
tic acid ;  or  by  means  of  red-hot  steel  rods,  applied  to  three  or 
four  spots  upon  the  exterior  surface,  avoiding  the  os  uteri.  Some- 
times the  solid  nitrate  of  silver  may  be  applied,  and  even,  says 
Dr.  Thomas,  in  bad  cases  the  caustic  potash  or  the  actual  cautery. 
These  he  evidently  prescribes  with  reluctance,  reserving  them 
for  extreme  cases,  inasmuch  as,  he  says,  they  may  produce  great 
induration  of  tissue,  contraction  of  the  os,  etc.,  and  with  equal 
truth  he  might  have  added,  pelvic  cellulitis,  peritonitis,  and  often 
death. 

As  to  the  treatment  of  corporeal  metritis,  Dr.  Thomas  acknow- 
ledges himself  at  fault.  Neither  leeches  to  the  abdomen  or  neck 
of  the  uterus,  neither  counter-irritants  externally  or  to  the  cervix 
uteri,  whether  by  cantharides  or  caustics,  neither  the  actual  nor 
potential  cautery,  nor  alteratives,  nor  rest  in  bed,  are  efficient  or 
advisable.  He  considers  that  although  this  treatment  might  be 
justified  theoretically,  yet  practically  it  is  of  no  avail :  the  disease  is 
an  opprobrium  medicorum.  Might  we  not  suggest  as  a  more  legi- 
timate conclusion  that  the  whole  theory  is  radically  incorrect  ? 
No  wonder,  therefore,  that  it  is  not  sustained  by  experience.  If 
the  inflammatory  theory  were  to  be  abandoned  and  the  supposed 
inflamed  uterus  should  be  regarded  and  treated  as  an  "  irritable 
organ,^^  we  should  anticipate  a  far  better  result  from  Dr.  Thomas' 
experience,  and  this  so  called  opprobrium  medicorum  might  be 
removed,  perhaps  entirely,  from  the  learned  works  of  the  Gyne- 
cologist. 


PART  I. 

DISEASES   OF    IRRITATION. 


CHAPTER    I. 

NERVOUS    IRRITATION    AND    ITS    CONSEQUENCES. 

The  neurotic  diseases  of  women  have  always  excited  the  in- 
terest of  the  medical  profession.  Their  frequency,  their  variety, 
their  obscurity,  and  their  obstinacy  (hard  to  be  overcome  and 
strongly  disposed  to  return),  have  forced  them  on  the  attention  of 
the  profession.  The  sex  and  character  of  the  sufferers,  the  pain, 
the  spasms,  the  convulsions,  and  the  numerous  mental  and  cor- 
poreal disturbances  involving  the  happiness,  the  usefulness  of 
women,  and,  not  unfrequently,  engendering  much  suffering  for  a 
long  series  of  years,  rendering  death  preferable  to  life,  have  all 
greatly  enhanced  the  devotion  of  medical  men  to  this  class  of 
diseases ;  although  they  are  seldom  fatal  in  their  results,  and, 
after  the  lapse  of  time  and  the  change  of  state  or  circumstances, 
may  spontaneously  disappear. 

Their  frequency  and  the  degree  of  suffering  increase  with  the 
progress  of  society.  The  cultivation  of  the  mental  powers,  of 
the  sentiments  and  passions,  the  advance  of  civilization,  the  re- 
finements, the  indulgences,  the  luxuries,  even  the  character  of 
social  intercourse,  and  the  objects  of  business  and  pleasure,  all 
serve  to  augment  the  number  and  aggravate  the  severity  of 
nervous  diseases.  Modern  physicians  have  spent,  necessarily, 
much  talent  and  labor  in  determining  the  pathology  and  thera- 
peutics of  these  obscure  complaints,  with  a  degree  of  success,  it 
is  painful  to  record,  by  no  means  in  proportion  to  the  ability,  the 
anxieties,  and  the  industry  expended  in  the  effort.     At  present, 


68       NERVOUS    IRRITATION    AND    ITS    CONSEQUENCES. 

it  will  be  unnecessary  to  examine  the  results  of  all  that  has  been 
done,  or  to  point  out  the  mistakes  that  have  been  made  by 
teachers  and  authors.  During  the  last  thirty  years,  much  labor 
has  been  bestowed  upon  this  subject,  and  the  pathology  of  female 
diseases  has  been  greatly  elucidated.  Nevertheless,  many  and 
serious  discrepancies  of  opinion,  as  to  the  nature  and  treatment 
of  uterine  affections,  exist  among  practitioners,  several  of  which 
have  been  detailed  in  our  introductory  essay.  Suffice  it  to  say, 
that  the  want  of  perfect  success  is  not,  as  too  frequently  allowed 
even  by  medical  men,  an  "  opprobrium  medicorum."  Far  too 
much  of  the  best  talent  and  learning  of  an  intelligent  and  culti- 
vated profession  has  been  sedulously  devoted  to  this  subject  to 
sanction  any  such  imputation.  Much  has  been  done,  especially 
by  way  of  preparation  for  more  important  practical  results ;  and 
the  favored  man,  who  shall  indicate  any  decided  mode  of  reme- 
dial relief  to  the  distressing  and  painful  affections  of  the  female 
sex,  must  gratefully  acknowledge  his  indebtedness  to  his  learned 
and  diligent  predecessors  in  their  labors  for  science  and  humanity. 
The  want  of  success,  therefore,  is  referable,  not  to  the  want  of 
effort,  but  to  the  intrinsic  difficulties  of  all  complaints  connected 
with  living  bodies,  especially  of  those  affecting  the  subtle,  intan- 
gible, almost  inconceivable  functions  of  the  cerebro-spinal 
nervous  system ;  which  involves  alike  the  operations  of  mind  and 
body,  and  constitutes  the  grand  medium  of  communication 
between  the  spiritual  and  corporeal  nature  of  man. 

References  to  numerous  systematic  works  on  the  diseases  of 
women  will  reveal  to  the  industrious  student  what  has  been 
accomplished,  and  what  suggestions  have  been  made  as  to  the 
nature  and  treatment  of  their  complaints.  We  have  no  desire 
either  to  present  a  summary  of  the  labors  of  others,  or  to  give  a 
critical  review  of  their  opinions  and  practice.  Our  only  object 
is  to  record,  while  incidentally  alluding  to  what  others  have 
advanced,  our  own  opinions  and  practice,  the  result  mainly  of 
clinical  observations  made  during  a  laborious  practice  of  many 
years ;  nearly  thirty  of  which  have  been  spent  as  a  public  teacher 
on.  obstetrics  and  diseases  of  women  and  children.  Our  success 
in  the  treatment  of  these  diseases  has  been  so  encouraging,  that 
we  cannot  but  hope  that  a  mite  may  thus  be  contributed  to  the 
scientific  character  and  practical  utility  of  our  beloved  profession. 


DEFINITIONS.  69 

Definitions  and  Illustrations. — Under  the  denomination  of 
the  "  irritable  diseases'''  of  women  are  included  those  which,  more 
or  less  directly,  involve  the  cerebro-spinal  nervous  system.  Of 
course  they  are  very  numerous  and  diversified ;  but  nevertheless, 
they  so  often,  indeed  so  generally,  depend  on  some  local  irritation, 
that  their  apparently  varied,  complicated  and  mysterious  charac- 
ter will  be,  in  some  degree,  dissipated  by  a  close  analysis  of  their 
phenomena,  and  their  treatment  be  rendered  simpler  and  more 
efficient. 

Language  has  proved  to  be  very  deficient,  in  expressing  the 
ideas  of  medical  men  on  the  physiological  and  pathological  states 
of  living  tissues.  Hence,  words  are  employed,  more  or  less,  in 
a  metaphorical  sense.  The  word  "  action^''''  vital  action,  is  con- 
stantly, in  the  minds  of  many,  associated  with  contraction ;  and 
yet  how  seldom  is  contraction  visible  or  demonstrable  in  many 
states  of  the  tissues  and  organs  where  the  word  is  constantly  em- 
ployed ;  for  example,  the  action  of  the  eye  in  seeing,  of  the  ear 
in  bearing,  of  the  brain  in  its  perceptions,  volitions,  etc.  The 
word  "  irritation''^  is  almost  constantly  employed,  and  yet  very  sel- 
dom in  a  definite  sense,  or  with  any  precise  meaning.  All  this  is, 
in  a  great  degree,  unavoidable  from  the  imperfection  of  our  know- 
ledge as  well  as  from  the  paucity  of  language.  Hence,  in  order 
that  we  may  be  better  understood,  we  will  point  out  the  mean- 
ings that  will  be  attached  to  the  technical  words  employed. 

'■'■Irritability'^''  belongs  only  to  living  tissues;  it  is  the  capability  of 
receiving  impressions  from  any  agent — the  "  capability  of  being 
acted  upon" — whence  result  phenomena  characteristic  of  the  par- 
ticular tissue  involved,  and  of  the  nature  of  the  irritant.  It,  of 
course,  belongs  to  everything  that  has  life;  to  plants  as  well  as 
animals;  to  the  organic  molecular  cell  as  truly  as  to  the  most 
complicated  and  perfect  structure. 

The  agents  which  excite  or  disturb  the  irritability  of  the  tissues 
are  termed  "  irritants.''''  Those  which  depress  or  diminish  its  in- 
tensity are  called  ^'-  sedatives.''^  An  irritant,  acting  on  the  irrita- 
bility of  a  part,  produces  an  ^^  irritation.''^  A  sedative  causes  a 
state  of  '■'■sedation.''''  The  one  is  an  exaltation,  the  other  a  diminu- 
tion of  vital  excitement. 

It  has  been  proposed  to  apply  the  words  "  excitahility^''  "  excit- 
ants^'' and  "  excitation^''  or  "  excitement^''  to  the  healthy  state  of  the 
economy;  and  '''•irritability^''   '"'■  irritants^''  and    ^'■irritation''''  to  its 


70       NERVOUS    IRKITATION"    AND    ITS    CONSEQUENCES. 

morbid  condition.  The  suggestion  is  excellent,  but  the  habitual 
language  of  the  profession  will  hardly  render  it  practicable.  These 
expressions  have  long  been  used  as  synonyms,  each  being  applied 
to  the  physiological  as  well  as  to  the  pathological  states  of  the 
living  body.  Still,  it  should  be  remembered  that  the  one  is  more 
appropriate  to  the  healthy,  and  the  other  to  the  morbid  state. 
An  irritation,  therefore,  is  strictly  a  morbid  excitement. 

Irritability. — The  degree  of  excitability  or  irritability  varies 
in  all  animated  nature,  being  very  low  in  plants,  and  very  exalted, 
comparatively,  in  animals.  It  is  different  in  the  various  species 
of  the  vegetable  kingdom  ;  hence,  some  plants,  in  which  irritability 
is  often  evinced  in  a  marked  degree,  have  been  termed  "irritable 
plants."  In  the  animal  kingdom,  also,  it  varies,  being  often  in  the 
lower  forms  as  imperceptible  as  it  usually  is  in  the  vegetable:  but 
the  susceptibility  to  impressions  is  generally  much  greater ;  and 
becomes  more  developed  as  the  organization,  and,  of  course,  the 
functions  become  more  complicated.  lience  in  man^  the  head  of 
this  animal  creation,  the  susceptibility  to  impressions  is  intense 
and  productive  of  the  most  wonderful  phenomena,  both  in  health 
and  disease. 

In  the  human  race,  the  excitability  varies  at  the  different  periods 
of  life.  Infants  are  proverbially  sensitive.  Every  one  perceives 
how  easily  a  child  is  excited  by  light  and  by  sound.  And  the 
physician  has  abundant  proof  of  this  fact  in  the  study  of  the  causes 
of  its  diseases  and  the  effects  of  remedial  agents ;  for  instance,  a 
gastric  irritation,  hardly  to  be  complained  of  by  an  adult,  will 
produce  rapid  and  often  dangerous  convulsions  in  an  infant.  This 
susceptibility  diminishes  in  the  progress  of  life,  and  often  almost 
disappears  in  the  torpor  and  listlessness  of  advanced  years. 

Sex  modifies  irritability  in  a  remarkable  manner.  "Women, 
compared  with  men,  are  impressible  and  sensitive.  This  is  true 
of  their  organic,  but  especially  of  their  animal  life.  The  action 
of  their  heart  and  arteries  is  rapid,  their  secretions  and  excre- 
tions are  usually  abundant  and  very  readily  increased  or  dimi- 
nished. They  generate  animal  heat  rapidly ;  and  this  fanction, 
connected  with  the  ever  varying  fluctuations  of  the  circulation, 
is  also  easily  disturbed  in  the  several  portions  of  the  economy. 
Hence  arise  sudden  determinations  of  blood  to  the  head,  with  the 
development  of  sensations  of  heat,  as  in  the  phenomena  of  blush- 
ing, crying ;  and,  at  the  same  time,  a  corresponding  diminution 


DEGREE    OF    IRRITABILITY.  71 

of  excitement,  a  sedation,  in  other  tissues  or  organs,  as  in  the 
hands  and  feet.  The  sensibility  and  versatility  of  the  organs  of 
animal  life  are  most  remarkable  in  the  female  sex.  Their  sensa- 
tions are  all  delicate  and  acute,  making  powerful  impressions  on 
the  "  sensorium  commune,"  with  a  corresponding  influence  on 
the  muscular  system,  dependent,  as  all  know,  on  the  nervous  sys- 
tem. Hence  arises  the  ready  disturbance  of  the  heart,  stomach, 
bowels,  uterus,  etc.,  from  certain  cerebral  excitements;  hence  the 
rapidity  and  delicacy  of  their  muscular  movements,  giving  rise 
to  the  beauty  and  grace  which  shed  a  charm  over  the  motions  of 
woman.  The  same  susceptibility  of  the  cerebro-spinal  nervous 
system,  particularly  of  the  brain,  its  centre,  is  wonderfully  mani- 
fested in  all  the  mental  and  moral  peculiarities  of  the  female  sex. 
Hence  quickness  of  perception,  rapidity  of  thought,  brilliancy  of 
the  imagination,  susceptibility  to  what  is  pleasant  or  disagreeable, 
to  what  is  joyous  or  grievous,  strong  affections  and  passions,  ver- 
satility of  character,  mental  and  moral,  are  characteristic  of  woman. 
All  this  is  fully  confirmed,  to  the  most  casual  observer,  by  con- 
templating her  pathological  state.  Her  organic  actions  are  readily 
disturbed  by  slight  impressions  from  without  or  from  within ; 
while  her  animal  life  is  the  sport  of  almost  every  external  or  in- 
ternal impression  of  a  decided  character.  Hence  pains,  subsultus 
tendinum,  twitchings  of  the  muscles,  cramps,  spasms,  convulsions, 
as  well  as  an  infinite  variety  of  morbid  sensations,  are  exceed- 
ingly frequent  among  females,  as  compared  with  males.  Hence, 
also,  the  predisposition  to  delirium,  insanity,  and  to  various  per- 
versions of  the  intellectual  and  moral  powers,  so  numerous  and 
so  remarkable,  that  the  most  acute  metaphysician  or  theologian, 
as  well  as  the  most  talented  and  experienced  physician,  cannot 
decide  what  is  voluntary  or  involuntary,  what  is  physical  or 
spiritual,  or  where  moral  responsibility  ceases,  and  insanity 
begins. 

Women,  therefore,  are  '■'■  nervous  f  that  is,  more  impressible 
than  men.  They  are  much  more  so,  during  the  period  of  their 
menstrual  life,  say  from  fifteen  to  forty -five,  than  after  this  has 
terminated.  Their  susceptibilities  diminish  after  the  "change" 
has  occurred ;  and  their  character,  mental  and  moral,  then  some- 
what approximates  that  of  their  male  companion.  Their  diseases, 
therefore,  are  all  modified  by  this  nervous  temperament,  and  often 
are  purely  "  neurotic,^''  that  is,  irritations  of  the   cerebro-spinal 


72       NERVOUS    IRRITATION    AND    ITS    CONSEQUENCES, 

nervous  system,  involving  the  functions  of  organic  life  in  so 
trifling  or  secondary  a  manner,  that  these  last  demand  few  or  no 
attentions  in  practice. 

One  great  object  of  the  present  work  is  to  maintain  that,  in 
many  cases,  the  independence  of  nervous  diseases  is  complete; 
and  also  that,  when  complications  exist  demanding  therapeutical 
assistance,  the  neurotic  affection  is  often  of  primary  and  essential 
importance,  and  demands  the  chief  attention  of  the  practitioner. 

The  remark  must  be  made,  although  apparently  unnecessary, 
that  these  neurotic  complaints  are  physical;  they  are,  in  every 
way,  as  much  real  diseases  as  those  of  organic  life.  They  are 
irritations  of  the  medullary  matter  of  the  brain,  of  the  spinal  cord, 
and  of  their  radiations,  the  nerves ;  as  truly  as  organic  diseases, 
inflammations,  fevers,  etc.,  are  irritations  of  the  heart,  arteries, 
capillaries,  and  organic  cells.  Since,  therefore,  the  cerebrum  is 
the  organ  of  the  mind,  as  well  as  of  the  body,  and  mental  and 
moral  causes  may  give  origin  to  nervous  diseases,  and  since 
remedies  of  an  intellectual  and  moral  character  contribute  to  re- 
covery in  nervous  affections  ;  it  is  unscientific,  as  well  as  unjust 
and  cruel,  to  maintain  that  such  diseases  are  mental  or  moral,  a 
perversion  of  the  "intellect  or  the  heart,"  that  they  are  "imagi- 
nary," a  "mere  notion,"  that  the  patient  is  "affected,"  wishes  to 
be  "interesting,"  to  attract  "attention,"  "has  a  bad  temper,"  and 
that  she  would  recover  "if  she  made  the  effort,"  "if  she  were 
forced  to  work,"  and  such  other  uncharitable  suggestions.  Let  it 
be  remembered,  that  the  business  of  the  physician  is  with  the 
physical  being :  and,  although  he  is  often  driven  to  the  domains 
of  the  mental  and  of  the  moral  philosopher,  to  detect  the  causes, 
or  to  furnish  the  remedial  agents  of  nervous  diseases,  yet  he 
should  be  slow  to  admit  that  his  agonized  patient  suffers  from  the 
state  of  her  mind  rather  than  of  her  body,  or  to  report  to  friends 
and  relations  that  this  would-be  patient  is  well,  when  her  con- 
sciousness tells  her  that  she  is  sick.  More  correct  mental,  as  well 
as  physical  science,  was  exhibited  by  a  distinguished  theologian, 
who  declared  that  cases  of  religious  melancholy  were,  by  him, 
always  transferred  to  the  physician. 

Irritability  varies  in  every  tissue  and  organ  of  the  economy :  in 
some  it  affords  but  trifling  evidences  of  its  existence,  as  in  ten- 
dons, ligaments,  cartilages,  bones,  etc. ;  in  others,  as  in  the  cutane- 
ous, muscular,  serous,  and  mucous  membranes,  it  is  easily  demon- 


MANIFESTATIONS    OF    IRRITABILITY.  73 

strable  to  the  eye,  and  in  the  nervous  system,  the  intensity  of  its 
manifestations  is  often  excessive.  Hence  it  results,  that  the 
phenomena  of  irritation  must  vary,  more  or  less,  in  every  tissue 
and  organ.  An  excitant,  acting  on  the  excitability  of  a  tissue  or 
organ,  causes  an  excitement,  which  is  an  increased  activity  of  its 
peculiar  vital  phenomena,  its  actions,  its  functions.  A  man  re- 
solves to  run  a  race;  the  mental  resolve  excites  his  brain,  spinal 
marrow,  motor  nerves,  and  muscles.  This  action,  in  turn,  excites 
his  heart,  arteries,  capillaries,  indeed,  his  whole  circulation.  We 
have  no  visible  indication  of  the  excitement  of  the  brain  and  its 
immediate  dependents,  under  the  stimulus  of  the  will ;  yet  we 
know  by  the  reflex  influences  on  other  tissues,  that  it  is  in  a  state 
of  excitement.  We  say,  that  cerebral  and  nervous  excitements 
are  known  by  the  changes  which  occur  in  their  functions,  and  in 
those  of  their  dependencies.  The  nerves  and  the  muscles  be- 
come excited,  by  reason  of  the  previous  excitation  of  the  brain. 
The  manifestation  of  excitement  in  the  muscles  is,  however, 
evident.  Excitement  in  this  tissue  is  sensibly  manifested  by  con- 
traction ;  which,  therefore,  is  the  evidence  of  the  excitability  or 
irritability  of  a  muscular  fibre.  Hence  an  irritant,  or  abnormal 
excitant,  produces  irregular,  and  often  painful  contractions  of  the 
muscles,  as  exhibited  in  cramps,  spasms,  clonic  and  tonic  convul- 
sive movements.  All  these,  therefore,  are  evidences  of  muscular 
irritation,  the  results  of  irritants  acting  on  the  irritability  of  the 
muscles,  and  are  due  to  the  peculiar  organization  and  functions  of 
this  distinct  tissue.  It  would  be  altogether  useless  to  sa}'-,  as  was 
formerly  done,  that  muscles  had  a  peculiar  vital  property  to  be 
termed  contractility.  This  would  be  merely  multiplying  words, 
as  no  new  idea  is  advanced,  and  would  seem  to  intimate  that  con- 
tractility differed  from  irritability  in  a  muscular  tissue,  which  it 
does  not.  It  is  still  more  objectionable  to  substitute  the  word 
contractility  for  irritability  as  a  universal  vital  property ;  for,  in 
very  many  cases  of  irritation,  no  contraction  can  be  demonstrated. 
In  running  a  race,  for  example,  the  circulation  is  excited.  The 
language  now  to  be  employed  to  indicate  the  excitement  of  its 
organs  is,  an  increased  contraction  and  dilatation  of  the  heart, 
arteries,  and  capillaries.  So,  also,  when  the  circulation  is  abnor- 
mally stimulated,  as  in  inflammation  and  fevers ;  we  say  that  an 
irritation  of  these  tissues  exists  manifested  by  the  same  phe- 
nomena of  contraction  and  dilatation,  one  or  both.     So  of  all  the 


7i      NERVOUS    IRRITATION    AND    ITS    CONSEQUENCES. 

tissues;  tbe  phenomena  resulting  from  an  excitant  or  an  irritant 
acting  on  their  irritability,  are  the  evidences  of  the  state  of  ex- 
citement or  irritation  thereby  induced.  This  is  true  everywhere 
in  the  organic  life,  as  in  disorders  of  nutrition,  secretion,  and 
excretion ;  and  so,  also,  in  the  animal  life,  as  in  disturbances  of 
sensation,  perception,  and  other  phenomena  interesting  the  nervous 
system.  This  is  a  general  principle,  a  universal  law,  however 
various  in  its  manifestations.  It  is  either  an  organic  or  animal 
irritation,  the  result  of  an  irritant  acting  on  the  irritability  of  the 
tissues  of  organic  or  animal  life.  Here,  also,  great  confusion  has 
been  excited  by  the  introduction  of  the  word  ^^ sensibility ^^^  when 
the  nervous  system  is  involved.  It  has  been  used  because,  in 
many  cases  of  nervous  irritation,  sensation  is  excited ;  and  it  is 
maintained  that  sensibility  is  a  peculiar  vital  property  of  the 
nervous  system,  as  contractility  of  the  muscular,  not  observing 
that  it  also  is  but  one  mode  of  manifesting  nervous  irritation, 
and,  probably,  by  no  means  the  most  frequent.  Muscular  con- 
tractions, in  health  and  disease,  are  usually  excited,  not  only 
Avithout  pain,  but  very  often  without  any  degree  of  sensation  or 
even  consciousness  on  the  part  of  the  patient;  yet  they  all  evince 
excitement  or  irritation  of  the  nerves  of  which  the  muscles  are 
the  organs,  or  the  agents.  It  therefore  avoids  confusion  to  sa}^, 
that  sensibility  in  the  cerebro-spinal  system  is  a  synonyme  with 
irritability  of  this  medullar}'-  tissue.  Hence,  nervous  irritation 
may  be  manifested  by  sensation,  internal  or  external,  of  whatever 
type  or  character;  by  muscular  contraction,  as  in  motion  or  in 
subsultus  tendinum,  spasms,  convulsions ;  and  also  by  the  dis- 
turbance of  the  mental  powers,  of  "  the  senses,"  and  indirectly  of 
the  functions  of  organic  life.  This  language  is  more  important, 
as  the  word  sensibility  has  been  applied,  by  some,  to  the  gangli- 
onic system  of  nerves,  and,  of  course,  also  to  organic  actions; 
where  it  is  not  only  irrelevant,  but  causes  Avrong  ideas,  as  in  such 
cases  there  is  strictly  no  sensation,  indeed  no  consciousness  of 
any  kind. 

To  indicate  more  clearly  the  precise  mode  in  which  the  words 
irritability  and  irritation  will  be  hereafter  employed,  and  to  ex- 
hibit its  importance,  one  or  two  illustrations  may  be  given. 

When  a  muscular  fibre  is  inflamed,  and  when  it  contracts,  we 
often  say  it  is  muscular  irritation,  in  the  one  case  as  well  as  in  the 
other ;  but  this  is  not  precise  language,  indeed  it  is  incorrect,  and 


ORGANIC    AND    NERVOUS    IRRITATIONS.  /O 

would  lead  to  improper  and  often  very  erroneous  pathological  and 
therapeutical  results.  Simple  contraction  is  merely  an  evidence 
of  muscular  irritation.  But  the  muscular,  in  common  with  every 
other  tissue  of  the  body,  is  the  subject  of  organic  life.  It  has, 
therefore,  its  circulation,  its  nutrition,  and  is  liable  to  the  diseases 
of  organic  life,  such  as  inflammation.  If,  then,  contraction  of  an 
inflamed  muscle  ensues,  as  it  frequently  will,  our  language  should 
be,  that  muscular  irritation  has  been  excited  by  inflammation, 
which  is  an  organic  irritation.  Hence,  also,  such  inflammations 
may  produce  muscular  contractions,  both  painful  and  spasmodic, 
in  all  the  neighboring  muscles,  while  no  inflammation  has  been 
propagated  to  them  from  the  tissue  originally  inflamed.  The 
practical  deduction  from  this  is  evident ;  the  indications  for  treat- 
ment in  the  one  case  of  inflamed  muscular  fibre — organic  irritation 
— will  be  diverse  from  that  of  pure  spasmodic  action — nervous 
irritation.  The  remedies  for  the  one  will  be  essentially  antiphlo- 
gistic ;  for  the  other,  antispasmodic.  Neither  need  this  patholo- 
gical view  be  at  all  modified,  because  inflammation  involving  par- 
ticularly the  organic  life  of  a  muscular  fibre  will  often,  and  indeed 
very  generally,  disturb  the  functions  of  the  muscles,  causing  con- 
traction, spasms,  etc.  In. such  complications  we  may,  simulta- 
neously, employ  both  classes  of  remedial  agents. 

In  affections  of  the  brain,  this  confused  use  of  the  word  irritation 
is  still  more  frequent.  Cerebral  irritation  exists,  say  from  moral 
causes;  confusion  of  ideas,  wandering  of  thoughts,  disturbed 
sensation,  spasmodic  actions,  even  convulsions  may  ensue ;  this  is 
true  cerebral  irritation ;  that  is,  irritation  of  the  cerebrum  as  an 
organ,  as  a  medullary  mass,  the  centre  of  the  nervous  system,  and 
also  as  the  instrument  of  the  mind.  To  employ  the  same  expres- 
sion, in  cases  of  acute  inflammation  of  the  brain,  is  very  common  ; 
but  manifestly  erroneous  in  theory  and  in  practice.  Cerebritis  is 
an  irritation  of  the  organic  life  of  the  brain,  of  its  bloodvessels, 
and  other  organic  tissues ;  and  not  of  medullary  nervous  matter. 
Sometimes,  as  after  wounds  of  the  brain,  inflammation  exists,  with 
few  or  no  evidences  of  functional  disturbance,  but  generally  the 
functions  are  disturbed ;  in  which  case  there  is,  of  course,  cere- 
bral or  nervous  irritation  superadded  to  inflammatory  or  organic 
irritation  of  the  tissues.  In  this  case,  the  chief  indication  is  to 
subdue  the  organic,  which  is  the  cause  of  the  animal  or  nervous 
irritation. 


76       NERVOUS    IRRITATION    AND    ITS    CONSEQUENCES. 

We  shall  have  constant  reference  to  this  distinction,  and  to  its 
importance  as  respects  the  affections  of  the  uterus.  It  is  sufficient 
at  present  to  allude  to  what  every  one  will  grant  at  once  ;  the  vast 
difference  between  uterine  irritation  as  it  exists  in  parturition, 
and  in  cases  of  metritis ;  in  other  words,  between  irritation  of  the 
uterus  as  the  subject  of  animal  life,  and  irritation  of  this  organ  as 
the  subject  of  organic  life.  How  different  is  the  treatment  for 
labor  and  that  for  inflammation  ! 

Congestion. — More  precise  meaning  should  be  attached  also  to 
the  word  "  congestion^''''  so  intimately  associated  with  all  our  patho- 
logical speculations.  From  its  etymology,  the  word  indicates  that 
there  is  an  unusual  quantity  of  blood  in  a  tissue  or  an  organ  ;  this 
is  its  proper  meaning.  Observation,  however,  shows  that  the  un- 
natural fulness  of  the  vessels  of  a  part  depends  on  different,  and 
sometimes,  opposing  causes.  Hence,  there  are  different  kinds  of 
congestions  or  '■^  engorgements ^  The  older  pathologists  were  very 
correct  in  distinguishing  between  active  and  passive  congestion  ; 
between  the  active  determination  of  blood  to  a  part,  and  the 
stagnation  or  arrest  of  blood  in  a  part.  The  acute  or  active 
congestion  is  generally  arterial ;  the  passive  congestion  more 
frequently  venous. 

Passive. — The  latter,  passive  congestion,  has,  perhaps,  been  too 
much  overlooked  by  the  modern  pathologist.  It  is  seen  in  vari- 
cose enlargement  of  the  veins;  in  cases  of  partial  or  complete 
obstruction  of  the  larger  veins ;  in  the  condition  of  the  circulation 
on  exposure  to  cold ;  in  cases  of  gangrene ;  in  asphyxia ;  in  the 
cold  stage  of  fevers,  etc.  In  all  such  cases  the  blood  is  not  ac- 
tively driven  to,  or  drawn  into  the  tissue ;  but  is  delayed  in  its 
progress  through  a  part.  The  consequences  are  various,  and  de- 
pend on  the  causes,  their  power,  the  continuance  of  their  influence, 
and  the  tissues  or  organs  involved.  If  congestion  continues,  more 
or  less  effusion  of  watery  or  sanguineous  fluid  ensues,  with  a  sub- 
sequent partial  or  total  suspension  of  the  functions  of  the  tissue 
or  organ.  Thus,  when  a  varicose  enlargement  of  the  veins  exists, 
the  limb  becomes  oedematous  or  anasarcous;  sometimes  bloody 
fluids  are  effused  from  the  smaller  vessels,  or  rupture  of  the  larger 
trunks.  Passive  congestions  of  the  brain  are  followed  by  the 
effusions  of  serum  or  blood ;  in  the  lungs,  there  is  great  disturb- 
ance of  respiration,  as  in  asphyxia,1ncrease  of  mucoid  fluids  from 
the  bronchial  passages.    Passive  congestions  of  the  portal  system 


VARIETIES    OF    CONGESTION.  77 

liave  beeii  recognized  by  most  pathologists,  as  disturbing  the 
functions  of  all  the  abdominal  viscera,  and  as  being  followed  by 
vomiting  and  purging  of  serous,  mucous,  or  bilious  matters,  and 
not  unfrequently  of  pure  blood,  as  in  haemoptysis,  hsematemesis, 
melaena,  etc.  In  the  more  intense  forms,  this  passive  congestion 
of  the  lungs,  these  seroid  and  sanguine  effusions  are  found  in  the 
parenchyma  of  the  lungs  or  upon  their  pleural  investment. 

Active. — As  regards  the  other  form,  or  active  congestion,  there 
are,  at  least,  two  varieties,  organic  and  nervous,  whicb,  although 
apparently  allied,  are  evidently  distinct  in  their  causes,  nature, 
and  results. 

"  Ubi  irritatio  ibi  aflfluxus,"  is  an  aphorism  as  true  as  it  is  trite, 
and  thence  arises  organic  congestion,  or  congestion  from  organic 
irritation,  as  in  inflammation.  A  local  irritation,  involving  the 
organic  actions,  is  followed  sooner  or  later,  in  living  tissues,  by 
an  enlargement  of  the  bloodvessels,  and  an  increase  in  the  quan- 
tity of  fluid,  until  inflammation  be  fully  developed.  This  is 
active  inflammatory  congestion,  as  excited  by  any  mechanical  or 
chemical  irritant.  The  consequences  of  inflammatory  congestion 
are  well  known,  in  the  swelling,  the  heat,  often  the  redness,  the 
pain,  the  effusions  of  peculiar  fluids ;  and,  if  continued,  in  the 
alteration  of  tissues,  and  their  ultimate  destruction  by  ulceration, 
gangrene,  and  sphacelus.  It  should  not  be  forgotten  that  inflam- 
matory irritation,  if  persistent,  is  a  disorganizing  and  destructive 
process,  and  even  in  its  chronic  varieties,  followed  by  alteration 
of  tissues,  ulcerations,  etc. 

The  second  variety  of  active  congestion  ought  to  be  carefully 
distinguished  from  the  above,  and  should  be  termed  simple  con- 
gestion, or  congestion  from  nervous  irritation.  Every  one  is 
familiar  with  the  frequent  determinations  of  blood  to  particular 
tissues  or  organs  in  health,  under  the  influence  of  nervous  ex- 
citement ;  for  example,  in  blushing,  flushes  of  heat,  crying ;  in 
the  erections  of  the  penis  and  nipple ;  in  the  salivary  and  mam- 
'  mary  glands ;  in  the  head  and  brain  from  excitements  from 
mental  and  moral  causes ;  in  the  uterus  previous  to  menstruation  ; 
indeed  in  all  the  organs,  under  their  normal  excitants,  when  new 
or  increased  demands  are  made  on  their  powers.  In  all  such 
instances,  there  is  evidently  excitation  and  a  consequent  active 
determination  of  blood  to  a  part,  not  only  without  injury,  but 
generally  productive  of  good,  in  furnishing  the  material  for  the 


78      NERVOUS    IRRITATION    AND    ITS    CONSEQUENCES. 

performance  of  the  respective  functions  of  the  tissues.  Such 
congestions  usually  disappear  spontaneously,  with  or  without 
increased  secretions.  In  the  erectile  tissues,  the  excitation  dis- 
appearing, the  fulness  of  the  vessels  subsides  rapidly.  Generally, 
however,  the  secretion  becomes  abundant,  as  in  the  shedding  of 
tears,  the  flow  of  saliva  from  the  mouth,  that  of  milk  from  the 
breast,  of  bile  from  the  liver,  of  the  menses  from  the  uterus. 
We  say,  therefore,  that  such  normal  excitements  and  congestions 
are  relieved  partly  by  the  disappearance  of  the  excitants,  but 
chiefly  by  a  free  secretion.  All,  however,  is  normal,  physiologi- 
cal, and  healthy.  Founded  on  this  normal  state,  there  is  an 
jtbnormal  state,  which  has  always  attracted  the  attention  of  the 
clinical  observer ;  but  the  marks  of  distinction  are  either  so 
indefinite,  or  so  difficult  to  be  drawn,  between  it  and  inflamma- 
tory irritation,  that  the  views,  and  of  coiirse  the  language  of 
pathologists  have  differed  exceedingly.  Their  ideas  have  been 
expressed  under  various  phrases,  such  as  congestion,  engorge- 
ment, apoplectic  state,  acute  inflammation,  subacute  inflamma- 
tion, mild  inflammation,  chronic  or  obscure  inflammation.  And 
these  conditions  have  been  very  universally  regarded,  if  not  as 
actually  inflammatory,  yet,  as  very  liable  to  terminate  in  inflam- 
mation, with  all  its  destructive  consequences,  ulceration,  disorga- 
nization, etc.^  Hence  the  practice,  founded  on  these  views,  has 
almost  always  been  antiphlogistic.  Experience  would  indicate 
that,  however  similar,  there  is  a  real  fundamental  distinction  to 
be  drawn  between  inflammatory  and  simple  congestion.  We 
have  examples  of  the  latter  in  most  of  these  cases,  so  constantly 
referred  to  by  authors  under  the  name  of  apoplexy  of  the  brain 
and  lungs,  engorgements  or  congestions  of  the  lungs,  liver, 
spleen,  bowels,  uterus,  etc.  This  is  precisely  analogous  to  the 
physiological  congestions  already  mentioned,  except  that  the  one 
is  normal  and  the  other  abnormal.  Usually  this  form  of  active 
congestion  occurs  suddenly,  unexpectedly,  but  often  approaches 
slowly,  insidiously ;  it  sometimes  disappears  rapidly,  but  more 
frequently  gradually  diminishes  as  the  irritation  subsides.  The 
consequences  of  this  congestion  are  sometimes  moderate,  and 
may  continue  for  a  long  time  without  serious  mischief,  but  are 
often  terrible  and  fatal ;  yet  in  all  cases  they  are  very  different 

'    Viile  Introductory  Essay. 


SIMPLE    CONGESTION.  79 

from  those  of  inflammation.  This  variety  in  the  results  depends 
mainly  on  the  importance  of  the  organ  involved,  as  well  as  on  the 
activity  and  intensity  of  the  nervous  irritation  and  congestion. 

Congestions  of  the  brain,  in  infants  and  adults,  afford  good 
illustrations  of  this  form  of  "  simple  congestion."  If  a  child  is 
tormented  with  gastric  irritation,  sudden  determination  to  the 
brain,  convulsions,  etc.,  will  often  follow.  A  man,  stimulated  by 
his  angry  passions,  has  an  attack  of  apoplexy,  from  which  he 
may  completely  recover ;  but  sometimes  his  recovery  is  tedious 
and  imperfect,  and,  occasionally,  death  speedily  ensues.  In  all 
such  cases  there  is  more  or  less  disturbance  or  suspension  of  cere- 
bral functions  and  influence;  thence  the  loss  of  consciousness,  or 
the  confusion  of  mental  powers,  the  convulsed  or  paralytic  con- 
dition of  the  voluntary  and  sometimes  even  of  the  involuntary 
muscles ;  hence  the  stertorous  breathing,  and  the  consequent 
congestions  of  the  lungs,  heart,  and  other  organs.  In  the  post- 
mortem examination  no  evidences  of  inflammatory  action  are 
visible ;  not  unfrequently  the  anatomist  reports  all  the  tissues  in 
a  normal  condition ;  generally,  however,  the  veins  are  distended, 
and  more  or  less  effusion  of  serous  fluid  is  found  in  the  cavity 
of  the  arachnoid  membrane  and  in  the  ventricles,  but  particu- 
larly in  the  subarachnoid  space  and  in  the  areolar  tissue  of  the 
pia  mater.  Occasionally  red  globules  are  commingled  with  the 
serum,  and  in  bad  cases  pure  blood  is  effused  on  the  surface,  in 
the  cavities  or  substance  of  the  brain. 

Effusion,  therefore,  if  the  congestion  be  severe  or  long-con- 
tinued, may  be  regarded  as  the  natural  consequence  of  simple 
congestion,  with  a  corresponding  interruption  or  suspension  of 
the  functions  of  the  organ  involved.  In  moderate  cases,  the 
turgescence  disappears  without  any,  or,  at  least,  trifling  effusion, 
and  the  organ  recovers  its  powers  on  the  subsidence  of  the  irri- 
tation. 

Where  secretory  surfaces  exist,  as  in  the  bronchial,  hepatic,  and 
uterine  tissues,  an  abundant  secretion  of  their  natural  fluids  ensues, 
and,  as  in  normal  excitements,  to  the  relief  of  the  engorged  vessels. 
Hence  the  free  secretion  of  mucus  in  the  lungs,  or  of  bile  in  the 
liver,  or  of  the  menstrual  fluid  in  the  uterus,  will  relieve  moderate 
congestions  of  their  respective  organs.  In  severe  cases  of  engorge- 
ment pure  blood  is  sometimes  effused,  as  in  haemoptysis,  hasma- 
temesis,  hasmorrhagia  uteri,  and  so  on  other  exposed  surfaces. 


80      NERVOUS    IRRITATION    AND    ITS    CONSEQUENCES. 

When  the  distension  of  the  vascular  tissue  of  an  organ  is  for 
a  long  time  kept  up,  from  the  persistence  of  the  cause,  it  some- 
times becomes  a  stimulus  to  the  organic  actions,  so  that  the 
nutritive  functions  are  more  actively  developed;  the  organ 
grows  in  size,  is  "hypertrophied,"  without  any  real  alteration 
in  the  character  of  its  tissues.  Hence  '■''hypertrophy^''  is  an  occa- 
sional consequent  of  chronic  nervous  congestion,  and  may  remain 
permaoent,  but  may  disappear  under  favorable  circumstances, 
when  the  cause  is  removed.  Hence,  we  have  one  cause  of 
hypertrophy  of  the  heart,  spleen,  liver,  uterus,  testes,  etc.,  in 
which  there  is  none  of  that  effusion  of  lymph,  that  indurated 
condition  or  disorganized  state  of  the  tissues,  which  are  the  con- 
sequences of  phlogosis.  Simple  hypertrophy  seldom  interferes, 
materially,  with  the  functions  of  the  enlarged  organ.  The  uterus, 
during  gestation,  may  be  considered  as  the  physiological  type  of 
the  uterus  in  a  state  of  active,  although  chronic  congestion. 

Whether  the  degree  of  organic  excitement  may,  in  cases  of 
acute  simple  congestion,  ever  become  so  intense  as  to  excite 
infiammation^  is,  and  must  be,  a  disputable  point,  as  so  many 
other  causes  are  often  operative.  Our  own  opinion  is,  that  simple 
congestion  is  never  the  cause  of  inflammation.  Inflammation  is 
not  one  of  its  sequelae.  Facts  on  this  point  will  be  hereafter 
adduced.^ 

Another  very  important  question,  and,  indeed,  not  less  so  than 
this  pathological  inquiry,  is  as  to  the  cause  of  simple  conges- 
tion or  engorgement.  Here  two  errors  seem  to  exist  in  prac- 
tice. Physicians  have  seldom  either  thought  of  or  investigated 
the  essential,  or  (to  use  the  good  but  neglected  name  of  the  older 
pathologists)  "the  proximate  cause"  of  sudden  determinations  of 
blood  to  tissues  or  organs.  The  remote  cauges  are  often  noticed, 
attended  to,  and  relieved  with  manifest  advantage;  but  few  inves- 
tigations or  inquiries  are  made  as  to  the  proximate  or  immediate 
cause.  For  example,  dentition  or  gastric  irritation,  in  a  child,  is 
frequently  followed  by  congestion  of  the  brain  and  convulsions. 
But  these  remote  causes,  as  every  one  knows,  often  exist,  and 
even  severely,  without  convulsions.  In  the  instances  stated,  the 
irritation  is  propagated  to  the  brain;  it  is  this  irritation  that 
causes  the  flow  of  blood  to  this  organ,  and  which  necessarily  pre- 

'   Vide  Introductory  Essay. 


THE    CAUSE    OF    SIMPLE    CONGESTION.  81 

cedes  the  congestion ;  "  ubi  irritatio,  ibi  affluxus."  The  imme- 
diate and  consequent  congestion  is  so  dangerous,  that  it  has  often 
occupied  all  attention  to  the  neglect  of  that  condition  or  state  of 
the  organ  which  preceded  the  congestion.  How  common  is  it  to 
read,  even  in  works  of  the  most  scientific  and  practical  men,  of 
congestion  of  an  organ  as  being  the  disease,  "ipse  morbus;"  and 
the  assertion  made,  if  the  congestion  be  relieved  the  patient  will 
necessarily  recover.  They  examine  not  as  to  the  present  state  of 
the  cerebral  mass,  or  whether  that  state  of  the  organ,  which  cer- 
tainly did  exist,  still  continues.  Hence,  because  they  find  evi- 
dences of  congestion  returning  with  wonderful  rapidity,  they  per- 
severe in  their  remedies,  until  the  strength,  health,  or  even  the 
powers  of  the  constitution  succumb.  A  lady  from  the  West  once 
informed  us  that  she  was  bled  almost  every  day  for  three  months, 
"  ad  deliquium  animi,"  for  a  congestive  headache,  and  became 
perfectly  anaemic,  and  without  permanent  relief. 

The  second  practical  error  is  to  confound  inflammation  with 
simple  congestion,  by  attributing  the  latter  as  well  as  the  former 
to  simple  organic  irritation ;  but  as  the  congestions  differ  as  to 
their  phenomena,  nature,  and  results,  they  must  have  different 
causes.  Experience  proves,  also,  that  the  treatment,  although  to 
some  extent  analogous,  must  often  be  very  different. 

Nervous  Irritation. — Nevertheless,  however  clearly  it  may  be 
demonstrated,  that  there  must  be  a  peculiar  cause  of  these  apo- 
plectic congestions,  not  to  be  confounded  with  other  causes,  and 
however  important  in  practice  the  distinction  ;  yet  it  is  impossible 
to  form  accurate  ideas,  and,  of  course,  to  convey  them  in  words, 
of  these  vital  states  or  conditions.  Perhaps  the  expression  "werv- 
o?<s"  or  "a?zrmanrritation,"  that  is,  an  irritation  of  certain  portions 
of  the  cerebro-spinal  nervous  system  at  its  centres,  or  its  ramifica- 
tions, may  be  ventured  upon ;  though  it  may  be  difficult  to  explain 
all  acute  or  chronic  congestions  by  reference  to  the  cerebro-spinal 
centres  and  ramifications.  It  seems,  however,  to  be  a  general 
truth,  that,  as  organic  irritation  causes  inflammatory  congestion^ 
so  nervous  irritation  causes  simple  congestion.  To  illustrate  this 
principle  several  examples  may  be  given,  as  the  distinction  is 
important  and  has  been  neglected. 

Mental  and  moral  affections  excite  the  brain.  Powerful  pas- 
sions, as  anger,  irritate  this  organ  ;  not  as  the  subject  of  organic 
life,  but  as  the  subject  of  animal  life,  as  a  medullary  mass.  This 
6 


82       NERVOUS    IRRITATION    AND    ITS    CONSEQUENCES. 

excitement  or  irritation  often  appears  and  disappears  without  any 
appreciable  disturbance  of  tbe  circulation.     This,  therefore,  is 
"  nervous  irritation."     In  this  case  it  is  manifested  by  the  exer- 
cise or  disturbance  of  the  mental  faculties,  by  the  expression  of 
the  eyes,  face,  or  by  corresponding  words,  motions,  etc.     No  one 
can  doubt,  in  sucla  a  state,  the  existence  of  cerebral  excitement, 
altbough  we  can  form  no  definite  idea  of  its  nature.     We  are  as 
ignorant  of  all  the  ever- varying,  inscrutable,  inconceivable  changes 
of  this  wonderful  organ  of  mind  and  body,  as  we  are  of  life  itself. 
As  we  employ  the  word  life  to  express  a  distinction  between  a 
living  and  a  dead  being,  so  we  employ  the  word  nervous  excitement, 
or  irritation,  to  express  the  distinction  between  the  quiescent  and 
the  active  condition  of  the  cerebral  tissue.     We  explain  nothing, 
we  simply  express  a  fact.     We  assert,  also,  by  this  expression 
that  it  is  not  an  organic  irritation,  not  an  irritation  of  the  vegeta- 
ble life  of  the  brain,  of  its  bloodvessels,  its  secretions,  its  nutrition, 
but  an  irritation  of  its  animal  life.     This  nervous  irritation  being 
continued  or  enhanced,  involves,  in  some  way,  the  circulation ; 
the  blood  rushes  to  the  organ  with  the  phenomena  and  conse- 
quences already  detailed.    We  have,  therefore,  the  mental  passion 
as  an  irritant,  producing  a  nervous  irritation  of  longer  or  shorter 
duration,  then  acute  congestion.     Without  the  irritation  of  the 
mass,  there  would  have  been  no  congestion.     The  congestion, 
therefore,  strictly  is  not  the  disease.     Irritation  is  the  true  com- 
plaint, and  the  afiiux  of  fluids  is  merely  a  symptom;  however 
dangerous  or  fatal  this  symptom  may  prove.     A  scientific  treat- 
ment, therefore,  is  not  completed  by  removing  the  congestion,  but 
demands  that  attention  be  paid  to  the  primary  state,  to  the  real 
disease.      Innumerable   examples  from  the  history  of  cerebral 
affections  indicate  the  truth  of  this  statement.    Nervous  irritation, 
confessedly,  exists  in  nervous  headaches  with,  as  well  as  without, 
congestion.     It  precedes,  therefore,  the  congestions  which  occur 
in  infantile  convulsions,  from  whatever  cause ;  as  well  as  in  epi- 
lepsy, in  hysteric  and  apoplectic  convulsions,  etc. 

Similar  examples  occur  in  laryngismus,  in  pertussis,  in  asthma, 
in  angina  pectoris,  and  in  all  the  varieties  of  gout  in  the  head,  heart, 
lungs,  stomach,  and  bowels.  In  all  aff'ections  of  the  spinal  marrow 
and  nerves,  it  is  accompanied  usually  with  more  or  less  pain, 
spasm,  and  cramp,  and  followed  sometimes  by  congestion,  which, 
when  it  is  present,  is  not  essential,  but  of  a  secondary  character 


INFLAMMATORY    CONGESTION.  83 

however  mischievous.  Hereafter,  these  principles  will  be  applied 
to  all  the  varieties  of  uterine  affections  and  their  consequences. 

The  correctness  of  these  principles  is  not  invalidated  by  the 
fact  that,  in  many  cases  of  post-mortem  examinations,  signs  of 
inflammation  are  detected  in  the  congested  tissues.  It  is  a  suffi- 
cient answer  to  say,  that  usually,  such  inflammatory  spots  are 
not  to  be  found,  and,  therefore,  the  acute  congestion  may  not  only 
exist,  but  be  so  violent  as  to  cause  death  by  itself  without  any 
inflammation.  Inflammation  has  nothing  to  do,  necessarily,  with 
congestions  of  this  type.  When  it  exists  it  is  as  a  complication, 
or  as  an  exciting  or  aggravating  cause  of  the  nervous  irritation. 

Some  decided  marks  of  distinction  may  now  be  drawn  between 
infiammatory  and  simple  congestions.  The  inflammatory  form  is 
a  disease  essentially  of  the  ganglionic  nervous  system  t»f  organic 
life.  It  arises  from  an  irritant  acting  on  the  organic  irritability ; 
and  causes,  therefore,  an  organic  irritation,  which  is  more  or  less 
speedily  followed  by  a  congestion,  first  and  chiefly  of  the  capil- 
lary vessels,  and  subsequently  of  the  larger  vessels.  It  begins 
at  spots  or  points  where  the  irritation  exists  most  intensely, 
although  diffused  to  other  parts;  and  is  followed,  if  the  cause 
continue,  by  morbid  secretions,  alteration  and  destruction  of 
tissues. 

The  simple  congestion  is  an  affection  of  the  cerebro-spinal 
nervous  system,  of  the  organs  of  animal  life.  It  is  caused  by 
peculiar  irritants,  acting  on  the  animal  irritability,  producing 
therefore  animal  irritation.  This  peculiar  state  of  irritation  of 
the  cerebral  system  is  not  always  followed  by  congestion ;  terri- 
ble indications  of  its  existence  are  often  observed  without  any, 
at  least  appreciable,  evidences  of  increased  vascularity.  Even 
when  congestion  is  present,  it  is  so  moderate  and  so  secondary, 
that  it  is  often  neglected  in  therapeutics.  When  congestion  does 
occur,  it  moves  with  wonderful  rapidity,  involving  at  once  large 
as  well  as  small  vessels,  the  whole  of  an  organ  as  speedily  as  a 
part,  the  adjacent  tissues  as  well  as  those  immediately  concerned. 
How  rapidly  will  a  transient  thought  mantle  the  face,  neck,  and 
breast  of  a  modest  young  woman  with  a  scarlet  blush !  How 
suddenly  will  a  cerebral  irritation  be  sometimes  followed  by  an 
apoplectic  congestion,  convulsions,  and  death !  How  instantane- 
ously will  the  thought  of  a  beloved  infant  send  the  arterial 
current  to  the  lachrymal  gland  and  its  appendages,  for  the  effu- 


84      NERVOUS    IRRITATION    AND    ITS    CONSEQUENCES. 

sioD  of  tears  of  joy  or  sorrow  ;  or  to  the  mammary  tissues,  for 
the  production  of  food  for  a  dependent  babe.  Such  congestions 
are  so  rapid,  that  in  common  language  we  speak  of  a  rush  of 
blood,  of  an  afflux,  or  sudden  determination,  of  engorgement,  etc. 

Great  as  these  congestions  may  be,  profuse  as  are  the  secretions 
or  the  ejBfusions  which  may  follow ;  still,  the  discharges  are  not 
morbid  in  their  character,  and  we  observe  no  disorganization. 
The  integrity  of  the  organ  remains  perfect,  unless  some  mechani- 
cal injury  ensues  from  the  effusion.  A  compression  or  laceration 
of  the  brain,  for  instance,  may,  of  course,  result,  when  blood  is 
poured  into  its  substance  or  cavities.  In  all  these  respects,  the 
distinctions  are  positive,  and  bear  most  decidedly,  as  will  be  here- 
after seen,  upon  the  indications  for  treatment,  and  on  the  choice 
of  therapeutical  agents. 

Although  much  has  been  already  said  of  the  distinction  between 
organic  and  nervous  irritation,  .perhaps  a  few  words  more  may  be 
demanded  for  illustration  of  a  neglected  and  abstruse  investigation. 

What  is  "  neuralgia  V  It  is,  as  its  name  imports,  a  variety  of 
nervous  irritation — in  common  parlance,  pain  ;  a  morbid  sensation 
of  a  painful  character  in  a  spinal  or  cerebral  nerve ;  an  irritation 
of  a  ^^  sensory  nerve,"  "a  nerve  of  sensation."  This  comprehends 
the  whole  idea.  No  other  meaning  ought  to  be  attached  to  it. 
But,  in  the  minds  of  many,  neuralgia  is  associated  almost  inva- 
riably with  inflammation.  With  them,  pain  in  a  part  is  a  syno- 
nyme  with  inflammation.  No  mistake  is  more  frequent  than  this 
in  pathology,  none  more  erroneous,  and  few  perhaps  more  inju- 
rious in  practice.  It  is  needless  to  multiply  examples  of  pain 
without  inflammation ;  every  one  has  experienced  pain  in  the 
ulnar  side  of  the  hand  and  little  finger  from  a  slight  blow  on  the 
ulnar  nerve  at  the  elbow ;  while  neuralgia  of  the  face,  eyes,  ears, 
and  of  the  brain,  stomach,  bowels,  and  uterus,  is  the  daily  obser- 
vation of  every  practitioner.  True  it  is,  inflammation  causes  pain 
in  very  many  instances,  and  the  latter  is  a  common  symptom  of 
some  modifications  of  organic  irritation,  when  the  irritation  ex- 
tends to  the  cerebral  nerves,  which  thus  become  involved ;  but 
there  is  no  necessary  connection  between  pain  and  inflammation. 
It  may  appear  strong  language,  but  pain  in  inflammation  is  an 
accident.  The  essential  phenomena  of  inflammation,  its  progress, 
its  results,  may  all  be  observed  where  no  pain,  sometimes  no 
sensation,  actually  exists.     Often  have  large  abscesses  been  dis- 


NEURALGIA.  85 

covered,  after  death,  in  the  brain,  lungs,  liver,  kidneys,  etc., 
where  no  suffering  had  ever  been  complained  of  during  life. 
In  inflammations  of  the  areolar  tissue,  tendons,  ligaments,  of  the 
mucous  membranes,  etc.,  no  pain  is  experienced,  except  in  com- 
plicated cases.  And  in  chronic  inflammations,  pain  is  generally 
absent. 

As  inflammation,  therefore,  may  exist  without  nervous  irrita- 
tion, so  neuralgia  may  often  exist  without  organic  irritation — a 
principle  of  fundamental  importance.  It  is  not  invalidated  by 
the  fact  that  neuralgia  is  frequently  the  consequence  of  inflam- 
mation. With  this  every  one  is  familiar.  A  diseased  tooth 
causes  neuralgia  of  the  facial  nerves ;  a  wounded  or  inflamed 
nerve  in  any  part  of  the  body  excites  the  most  painful  neuralgic 
symptoms  towards  its  sentient  extremities ;  cerebritis  and  mye- 
litis often  excite  agonizing  irritations  of  the  nerves  and  muscles 
of  the  trunk  and  extremities.  In,  all  such  instances  neuralgia  is 
a  nervous  irritation  superadded  to  that  of  inflammatory  irritation, 
and  indicating,  necessarily,  that  the  nerves  are  directly  or  indi- 
rectly involved  in  the  disease. 

Let  it  be  remarked,  also,  that  the  nervous  irritation  in  cases  of 
neuritis  is  propagated  not  merely  to  the  sentient  extremity  of  the 
nerve  affected,  but  often  in  the  opposite  direction,  along  the 
trunk,  to  the  centres;  hence  spinal  and  cerebral  irritations  are 
often  produced.  Many  examples  might  be  adduced,  and  some 
will  hereafter  be  presented.  Moreover,  the  irritation,  thus  carried 
to  the  spinal  marrow  or  the  brain,  is  often  deflected  or  reflected 
from  these  centres  to  other  nerves,  even  in  distant  parts  of  the 
economy.  Neuritis,  or  even  simple  irritation,  of  the  sciatic 
nerve  may  thas  be  "  perceived"  by  the  spinal  marrow  or  brain, 
and  then  it  may  be  reflected  to  the  nerves  of  the  upper  extremi- 
ties of  the  trunk,  and  even  of  the  viscera.  It  is  as  great  a  patho- 
logical error,  therefore,  to  consider  the  brain  or  the  spinal  cord 
the  seat  of  disease  merely  because  they  are  sensitive  or  painful, 
as  to  imagine  the  disease  is  in  the  fingers  or  toes  because  the 
patient  complains  of  pain  in  those  extreme  portions  of  the  limb. 
The  surgeons  have  long  been  familiar  with  this  principle,  as  in 
cases  of  pain  in  the  knee  in  "coxalgia"  or  "coxitis;"  and  it  is  a 
principle  of  universal  application. 

Nervous  irritation  in  a  motor  nerve  is  manifested  by  "spasms," 
"  cramps,"  "  clonic  and  tonic  convulsions."     The  muscles  are  the 


86      NERVOUS    IRRITATION    AND    ITS    CONSEQUENCES. 

instruments  of  the  cerebro-spinal  system,  and  are  excited  in 
health  or  irritated  in  disease  by  the  ever- varying  conditions  of 
the  nerve  centres.  A  spasm  is  an  inordinate,  irregular  action  of 
the  muscular  fibres ;  it  is  seen  both  in  the  voluntary  muscles  in 
the  form  of  subsultus  tendinum,  cramps,  spasms,  etc.,  and  in  the 
involuntary  muscles,  as  in  laryngismus,  palpitations  of  the  heart, 
gastrodynia,  colics,  etc.  When  the  cerebro-spinal  centres  are 
involved,  these  spasmodic  actions,  influencing  large  portions  of 
the  muscular  system,  are  termed  clonic  or  tonic  convulsions; 
hence  we  speak  of  hysteric,  epileptic,  and  tetanic  convulsions. 
In  all  such  cases  of  spasms  and  convulsions,  pain  is  very  rare; 
but  in  other  cases,  termed  rigidities  or  cramps,  where  there  is  a 
tonic  contraction  of  the  muscles,  there  is  often  severe  pain,  for 
now  the  sensitive  nerves  appear  to  be  involved.  All  these  are 
the  various  manifestations  of  nervous  irritation,  existing  by  itself, 
or  complicated  with  acute  or  passive  congestions,  or  with  organic 
or  inflammatory  irritation. 

We  have  examples  of  simple  nervous  irritation  of  motor 
nerves  in  the  spasms  and  convulsive  movements  in  pure  cases  of 
the  risus  sardonicus,  of  laryngismus,  of  spasmodic  croup,  of  per- 
tussis, of  asthma,  of  many  cases  of  palpitatio  cordis,  of  chorea, 
etc.  In  other  instances,  these  spasms  are  complicated  with  irri- 
tation of  the  nerves  of  sensation;  thus  in  the  stomach  we  have 
gastrodynia ;  in  the  intestines,  colic ;  in  the  uterus,  dysmen- 
orrhoea. 

The  more  general  spasms  of  the  muscles  can  usually  be  traced 
to  the  spinal  or  cerebral  centres.  In  the  former  case  there  are, 
often,  but  few  symptoms  of  congestion;  in  the  latter,  occasionally, 
there  is  no  congestion,  but  often  the  most  intense  symptoms  of 
passive  or  active  congestion  are  present.  In  chorea,  hysteria, 
and  especially  in  hysteric  convulsions,  few  evidences  of  conges- 
tion of  the  spinal  cord  or  brain  are  observed ;  but  in  apoplectic, 
puerperal,  and  tetanic  convulsions  the  indications  of  congestion 
are  very  decided ;  yet  in  all,  nervous  irritation  precedes,  and  pro- 
bably constitutes,  the  essential  character  of  the  disease.  In  cere- 
britis  and  myelitis,  spasms,  cramps,  and  convulsions  appear,  as 
already  remarked,  among  the  important  symptoms  of  the  internal 
disease,  the  essential  characteristic  of  which,  in  these  cases,  is 
inflammation  or  organic  irritation. 

But  nervous  irritation  is  not  only  manifested  by  decided  pain. 


MORBID    SENSATIONS.  87 

or  by  spasms  and  convulsions,  but  by  an  innumerable  variety  of 
morbid  feelings  and  seris'dions,  frequently  of  trifling  importance, 
but  often  of  such  a  distressing,  horrible  character,  that  severe 
pain,  or  even  death  itself  would  be  preferred.  In  health  the 
exercise  of  our  senses,  the  indulgence  of  our  tastes,  and  even  of 
our  passions,  in  a  moderate  degree,  is  pleasant  and  exhilarating, 
through  the  medium  of  nerves  conveying  the  impressions  re- 
ceived to  the  sensorium  commune ;  but  in  disease,  whether  local 
or  general,  of  the  sensitive  apparatus,  the  impressions  are  dis- 
agreeable, and  may  be  tormenting,  though  not  always  painful. 
How  often  is  light  distressing  to  the  eye,  and  sound  to  the  ear, 
under  the  influence  of  nervous  excitement !  How  often  is  the 
sense  of  smell  and  taste  perverted ;  so,  as  in  a  case  now  under  our 
notice,  the  perfume  of  the  rose  is  fetid,  and  of  the  honeysuckle, 
positively  disagreeable  !  In  disease,  patients  often  complain — of 
a  sensation  of  opening  and  shutting  of  the  bones  of  the  head ;  of 
coldness,  or  of  heat,  when  the  body  is  in  a  directly  opposite  con- 
dition, perhaps  insisting  that  a  cold  bath  is  demanded,  when  the 
pulse  has  failed  and  the  surface  of  the  body  covered  with  the  cold 
sweat  of  death ;  of  a  feeling,  as  if  the  head,  the  heart,  or  the  whole 
body  was  immensely  enlarged ;  of  palpitations  of  the  heart  when 
there  is  no  fixed  disease  of  the  organ ;  of  suspension  of  its  func- 
tions when  its  action  is  perfect ;  of  sensations  of  oppression  about 
the  prsecordia ;  of  a  feeling  of  sinking,  of  exhaustion  (a  "  die-away" 
feeling),  as  if  suffocation  or  death  must  immediately  ensue  ;  of 
great  languor  when  there  is  an  apparent  abundance  of  strength. 
Besides,  there  are  various  other  internal  distresses,  which  are 
inexpressible,  and  not  to  be  conceived  of  by  those  who  have  not 
suffered  in  like  manner;  and  of  which  some  general  idea  is  given 
by  such  expressions  as  uncomfortable,  "  malaise,"  miserable, 
wretched,  nervous,  low  spirits,  distress,  agony.  Sometimes  the 
condition  is  absolutely  intolerable,  and  causes  syncope,  catalepsy, 
and  convulsions,  to  the  temporary  relief  of  the  unhappy  sufferer. 
These  morbid  sensations  and  irritations  are  as  truly  physical 
evils,  as  organic  irritations  from  the  puncture  of  a  thorn  or  a 
lancet,  from  an  inflammation  or  a  fever.  It  is  not  imaginary,  a 
mere  notion,  a  phantom,  conjured  up  for  effect,  to  interest  friends, 
to  excite  sympathy  or  alarm.  Nor  is  it  bad  temper,  nor  a  wilful 
indisposition,  but  a  genuine  evidence  of  nervous  disturbance. 
And  however  ignorant  of  it  the  physician  or  attendant  may  be, 


88       NERVOUS    IRRITATION    AND    ITS    CONSEQUENCES. 

there  is  a  cause,  an  irritant,  somewliere,  producing  irritation.  The 
symptoms,  therefore,  are  referable  not  to  the  mind  or  the  heart, 
but  to  the  physical  being.  These  varieties  of  nervous  irritation, 
these  morbid  sensations,  are  often  chiefly  evinced  in  the  altered 
state  of  the  morale  of  the  patient ;  because  the  mind  depends  for 
its  healthy  exercise  on  the  normal  state  of  the  brain,  its  instru- 
ment. If  the  instrument  be  out  of  tune,  discordant  notes  will 
ensue.  Many  patients  are  unamiable,  cross,  passionate,  low 
spirited,  melancholic,  simply  from  some  corporeal  irritation.  A 
little  medical  treatment  will  often  dissipate  these  "vapors,"  and 
restore  peace  and  happiness  far  more  readily  than  moral  suasion. 
Of  course,  every  one  is  aware  of  the  opposing  fact,  that  moral 
causes  will  produce  physical  disturbances.  Mind  affects  the  body 
through  the  medium  of  the  brain  and  its  dependencies.  States 
of  the  mind  will  cause  nervous  irritation  or  sedation,  and,  of 
course,  active  or  passive  congestions,  whence  arise  interruptions 
of  the  functions  of  organs  to  even  a  fatal  extent.  Anger  may 
produce  apoplexy.     A  man  may  die  of  a  "  broken  heart." 

It  is  this  action  and  reaction  between  body  and  mind,  and  mind 
and  body,  through  their  common  medium,  the  cerebral  mass, 
which  continually  meet  the  physician  in  his  daily  visits,  either 
as  cause  or  effect,  complicating  the  symptoms  and  often  demand- 
ing all  his  therapeutic  efforts.  Attention  should,  of  course,  be 
paid  to  the  spiritual  as  well  as  to  the  physical  being.  The  moral 
treatment  is  often  as  important  as  the  physical,  and  in  all  cases, 
facilitates  the  recovery  from  corporeal  diseases. 

Again,  nervous  excitement  or  irritation  should  not  be  con- 
founded with  vital  power  or  strength.  The  difference  between  them 
is  very  obvious,  but  not  unfrequently  neglected  in  practice ;  and 
the  mistake  is  not,  always,  easily  avoided.  Excitement  of  a  tissue 
or  organ  is  a  manifestation  of  its  power ;  but  the  excitement  may 
be  very  great  when  the  power  is  trifling,  or  the  power  may  be  very 
great  when  the  excitement  is  nearly  or  altogether  suspended.  A 
strong  man,  asleep,  has  great  power,  though  not  in  exercise.  A 
weak  man,  stimulated  by  anger  or  alcohol,  will  manifest  great 
excitement ;  but  he  wants  power,  and  soon  sinks  exhausted. 

Vital  power  may  be  defined,  as  the  capability  of  living  tissues, 
not  only  to  act,  but  to  endure  action ;  not  only  to  resist,  but  to 
resist  long ;  a  capability  of  resisting  or  enduring,  as  well  as  of 


VITAL    POWER.  89 

acting.  The  degree  of  power  is  not  easily  estimated ;  and  of 
course  it  is  ever  varying.  In  the  weak,  power  is  soon  exhausted 
by  a  given  excitement ;  the  same  degree  of  excitement  may  be, 
for  a  long  time,  borne  by  one  of  a  good  constitution.  To  exhaust 
the  strong  man,  the  excitement  must  be  increased,  it  must  be  in- 
ordinate. Under  such  excitements,  congestions,  effusions,  and 
even  death  may  soon  result.  Excitement,  irritation,  action,  there- 
fore, exhaust  power.  The  greater  the  excitement,  caeteris  paribus^ 
the  sooner  power  is  exhausted.  Debility,  a  mere  diminution  of 
vital  strength,  collapse  or  prostration,  a  failure  of  the  vis  viise, 
may  ensue,  therefore,  either  from  the  degree  of  excitation,  or  from 
the  want  of  power.  A  severe  irritation  causes  collapse  in  the 
strong,  but  the  same  collapse  occurs  from  a  mild  excitement  in 
the  feeble. 

These  expressions,  thus  defined,  are  in  accordance  with  com- 
mon language  in,  and  out  of,  the  profession ;  and,  of  course, 
with  the  usual  observation,  experience,  and  reflection  of  all  men. 
The  man  of  pure  science  may  insist  that  the  language  is  too 
general,  that  it  is  not  definite,  and  that  no  precise  idea  is  con- 
veyed. He  would  speak,  therefore,  of  various  kinds  of  "  vitcd 
force^''  of  '■'■formative  power^''''  of  '■'■organic  forcej''  of  ^'■dynamic 
power ^''  of  the  "  nervous  excitor^''  and  ^'■motor''^  forces,  and  of  ^^ mus- 
cular contractility  r 

But  is  our  real  knowledge  increased  by  this  multiplicity  of 
words?  Every  part  of  the  body  is  alive;  has  its  irritability,  is 
capable  of  receiving  impressions,  and  of  manifesting  this  irrita- 
bility in  its  own  way ;  it  has  its  own  excitations,  its  own  actions, 
its  own  functions ;  each  part  can  endure  its  own  excitements  for  a 
longer  or  shorter  time,  in  proportion  to  its  vital  strength,  but  de- 
bility or  prostration  may  sooner  or  later  occur.  Although  each 
tissue  has  its  own  manifestations  of  vitality  and  its  own  functions, 
yet  the  nature  of  power  is  everywhere  the  same,  modified,  in  its 
results,  by  the  tissue  or  organ  concerned.  A  skilful  musician 
may  be  regarded  as  manifesting  the  same  ability ;  whether  he 
"  discourses  sweet  sounds"  through  the  medium  of  the  violin,  the 
flute,  the  harp,  or  the  full-toned  organ.  These  ideas  are  capable 
of  indefinite  illustration  in  all  parts  of  the  economy,  in  the  organs 
of  the  cerebro-spinal  system,  as  well  as  in  those  of  the  organic 
life,  represented,  as  it  is  supposed  to  be,  by  the  ganglionic  system 
of  nerves.     Constant  excitement  exhausts  power.     A  diminution 


90       NERVOUS    IRRITATION    AND    ITS    CONSEQUENCES. 

of  excitement,  rest  (partial  or  complete),  is  demanded  for  recu- 
peration, for  the  renewal  of  power.  This  is  especially  evident  in 
the  brain  and  its  dependencies ;  but  is  true  even  of  the  heart  and 
its  accessories,  with  all  their  complicated  and  never  ceasing  invo- 
luntary functions. 

This  distinction  between  vital  power  and  excitement  is  ob- 
served in  the  cerebrospinal  nervoiLS  system.  Under  the  inordinate 
stimulus  of  anger,  fear,  and  other  passions,  the  brain  becomes  so 
excited  as  to  reflect  its  excitations  on  the  muscles  of  the  face,  ex- 
tremities, and,  indeed,  on  all  the  muscular  system.  Violent  efforts 
ensue,  and  wonderful  energy  is  manifested ;  but  it  cannot  be  kept 
up  for  any  great  length  of  time.  The  exertions  gradually  dimi- 
nish, and  finally  cease ;  or,  if  the  cause  continue,  syncope  or  even 
death  may  ensue.  The  horse  or  the  dog  of  the  hunter  often  falls 
before  the  prize  is  won  ;  they  sink  exhausted,  or  die.  What  bet- 
ter language  expresses  this  known  fact  than  to  say,  their  power 
is  exhausted,  their  forces  are  expended,  by  the  violent  efforts  of 
the  organs  of  animal  life.  A  horse  or  a  dog,  of  relatively  great 
strength,  will  endure,  for  a  long  time,  the  unusual  effort ;  those 
comparatively  weak,  soon  succumb.  An  excitation  of  portions 
of  the  nervous  system  will  be  endured  for  a  long  time,  if  the 
general  system  is  not  much  involved  :  nevertheless,  the  continued 
excitement  of  any  set  of  muscles,  or  of  an  organ,  is  followed  by 
fatigue,  exhaustion,  it  may  be  by  paralysis,  or  a  complete  failure 
of  "nerve  force,"  that  is,  of  vital  power  manifested  through  the 
medium  of  the  nerves.  Paralysis  of  the  upper  and  lower  extre- 
mities, of  the  nerve  of  the  eye,  or  that  of  the  ear,  is  often  brought 
on  by  over-excitation. 

The  same  distinction  between  strength  and  action  is  also  ob- 
served in  the  organs  of  organic  life.  Every  physician  speaks  of  a 
failure  of  power,  of  debility,  of  prostration,  or  of  collapse,  in  pro- 
tracted cases  of  fever,  cholera,  etc.  Tonics,  stimuli,  natural  and 
artificial,  are  employed,  but  often  in  vain ;  the  patient  continues 
to  sink,  and  dies.  One  soon  perishes,  another  struggles  for  a  long 
time,  a  third  may  react^  and  may  survive.  All  this  language  has 
respect  to  the  organic  force.  In  all  fevers  patients  complain  of 
great  sensations  of  weakness,  exhaustion,  from  the  disturbance  of 
the  nervous  system  ;  but  their  organic  powers  are  often  great,  and 
the  irritation  so  severe  that  evacuants  are  demanded.  Under  the 
excitement,  therefore,  of  the  heart,  arteries,  capillaries,  etc.,  col- 


EXCITEMENT    IS    NOT    POWER.  91 

lapse  may  ensue,  power  may  fail,  debility  and  exhaustion  may 
follow. 

Any  portion  of  the  animal  economy  may  suffer  in  tlie  same 
manner.  What  is  true  of  the  whole  system  is  equally  true 
of  any  portion  of  the  organic  tissues,  however  evident,  or  how- 
ever imperceptible,  may  be  the  development  of  its  functions. 
"  The  action  is  often  too  great  for  its  power,^^  is  a  Hunterian  maxim, 
which  no  surgeon  neglects  in  his  practice,  whatever  may  be  his 
theoretical  views.  In  phlegmonous  inflammation  of  an  intense 
character,  if  gangrene  and  sphacelus  occur,  it  is  precisely  at  that 
point  where  the  inflammation  is  most  violent,  and  is  surrounded 
by  zones,  exhibiting  the  different  degrees  of  inflammatory  action, 
as  the  ulcerative,  the  suppurative,  the  lymphatic  or  adhesive,  and 
the  serous.  This  fact  of  every-day  observation  is  most  frequently 
and  most  appropriately  expressed  by  the  language  that  excite- 
ment has  been  too  great,  the  strength  of  the  part  has  failed,  spha- 
celus or  death  has  ensued.  Precisely  as  collapse  takes  place  in  fever, 
collapse  and  gangrene  occur  in  inflammation.  Power,  or  the 
capability  of  exciting  and  keeping  up  action,  fails,  from  the  vio- 
lence or  the  persistence  of  the  excitement.  Hence  those  tissues 
which  have  comparatively  least  vital  power,  are  the  first  to  perish  ; 
as  cellular  tissue,  ligaments,  tendons,  cartilages :  while  the  skin, 
muscles,  arteries,  veins,  and  nerves,  will  often  maintain  their  in- 
tegrity in  the  midst  of  a  sloughing  abscess.  The  sloughing  of 
cellular  tissues  is,  almost  universally,  much  more  extensive  than 
that  of  the  skin  which  covers  it ;  tendons  usually  slough  all  the 
way  up  to  the  muscles  with  which  they  are  connected ;  the 
sloughing  of  a  bone,  "necrosis,"  occurs  higher  up  than  that  of  the 
soft  parts.  All  these  are  facts  of  difficult  explanation,  should  we 
venture  to  analyze  them  very  minutely;  but  the  general  truth  is 
evident,  the  lower  the  vitality  and  the  less  perfect  the  organiza- 
tion, the  more  feeble  the  manifestation  of  organic  functions,  the 
sooner  and  the  more  extensive  will  be  the  collapse.  The  same 
truth  is  exemplified,  also,  by  the  fact  that  gangrene  occurs  more 
readily  in  the  old  than  in  the  young,  in  the  intemperate  than  the 
temperate,  in  the  patient  debilitated  by  famine  or  fever,  than  in 
the  healthy  and  strong. 

This  general  principle  is  not  invalidated  by  the  assertion  often 
made,  that  collapse  results  because  congestion  occurs,  the  blood 
becoming  stagnant  in  the  veins,  lungs,  heart,  etc.,  or  in  the  small 


92      NERVOUS    IRRITATION    AND    ITS    CONSEQUENCES. 

vessels.  But  this  slow  circulation,  this  stagnation,  is  part  of  the 
dying  process,  of  the  state  of  collapse,  of  gangrene,  and  is  due  to 
the  loss  of  power  in  the  circulatory  tissues.  The  intensity  of  the 
vascular  excitement,  and  the  rapid  movement  of  the  blood,  con- 
tinue until  the  power  of  the  general  or  local  circulation  dimi- 
nishes ;  then  the  blood  moves  with  less  rapidity,  its  momentum 
diminishes,  the  organic  actions  fail,  and  death  ensues. 

Action,  that  is,  excitement  or  irritation,  ought  not,  therefore,  to 
be  confounded  with  power.  It  is  certainly  a  manifestation  of 
power,  as  there  can  be  no  action  where  there  is  no  power  to  act ;  but 
the  action  may  be  intense  when  the  strength  is  feeble,  as  in  the 
habitual  drunkard  under  the  influence  of  a  strong  alcoholic  stim- 
ulus, and  as  in  the  old  man  with  a  high  fever.  The  practitioner 
makes  often  a  fatal  mistake,  who  resorts  to  his  nauseating  reme- 
dies in  the  case  of  the  intemperate  and  aged,  as  he  would  in  the 
healthy  and  the  young ;  or  perseveres  in  a  low  diet  and  bleeding, 
in  an  exhausted  patient,  because  a  local  inflammation,  even  in  an 
important  organ,  exists.  The  disease  may  be  cured,  but  the  patient 
dies ;  or,  what  is  more  frequently  the  case,  the  disease  continues, 
and  the  patient's  constitution  is  broken  down  and  irreparably  in- 
jured. 

The  reverse  is  of  course  true ;  there  may  be  moderate  action 
where  there  is  great  power,  as  during  sleep,  and  during  the  tor- 
pidity from  cold  or  a  narcotic  poison.  In  such  cases  stimuli  may 
be  demanded  to  excite  more  action,  but  if  they  be  too  freely  used, 
the  reaction  is  often  inordinate,  and  even  fatal.  The  gangrene 
from  heat  applied  to  frosted  limbs  is  a  familiar  example  of  this, 
as  well  as  the  dangerous  apoplectic  congestions  which  result 
under  similar  circumstances,  after  universal  torpor  from  cold. 

A  most  important  principle,  involved  in  these  distinctions  be- 
tween power  and  action,  is,  that  the  irritability  of  a  part  is  inversely 
as  its  strength.  The  greater  the  power,  cseteris  paribus,  the  less  the 
excitability ;  the  weaker  the  part,  the  greater  the  excitability. 
This,  of  course,  applies  to  each  tissue  in  reference  to  its  own  . 
actions  and  powers,  and  not  comparatively  as  it  relates  to  other 
tissues.  We  cannot,  for  example,  say  that  the  cellular  tissue, 
because  its  organic  life  is  comparatively  feeble,  is  therefore  more 
excitable  than  the  skin,  with  its  abundant  supply  of  bloodvessels 
and  nerves.  This  principle  is  applicable  both  to  the  animal  and 
to  the  organic  life.     A  strong  man  is  said  to  have  "  no  nerves" — 


IRRITABILITY    INVERSELY    AS    THE    STRENGTH.        93 

that  is,  it  requires  powerful  impressions  to  disturb  his  mental  and 
physical  susceptibilities.  In  comparison,  a  woman  is  "  nervous," 
"all  nerve" — that  is,  impressible,  sensitive.  Minor  causes  will 
disturb  her  mind  and  body ;  powerful  impressions  will  produce 
great  agitations  of  her  mental  and  moral  being,  and  of  all  the 
tissues  under  the  domain  of  the  cerebro-spinal  system.  Hence 
laughing,  crying,  screaming,  delirium,  syncope,  insensibility, 
asthmatic  breathing,  palpitations  of  the  heart,  subsultus  tendi- 
num,  spasms,  cramps,  and  convulsions  are  more  common  among 
women  than  among  men.  Let  the  strong  man,  however,  be  weak- 
ened in  any  way — by  bleeding,  diarrhoea,  fever ;  or  by  the  want 
of  food,  of  rest,  of  sleep ;  or  by  over-exertion,  long-continued 
fatigue — and  he  also  will  become  "nervous."  His  mind  becomes 
excitable,  and  his  body  keenly  susceptible  to  every  impression. 
As  he  regains  his  strength,  his  irritability  diminishes,  and  he  is 
less  sensitive,  less  impressible. 

To  this  general  principle  there  is  perhaps  no  positive,  but  many 
apparent^  exceptions.  Many  persons  are  very  nervous  even  when 
in  perfect  health  and  strength,  It  is  their  peculiarity  ;  they  are 
of  a  nervous  temperament.  Some,  also,  may  become  nervous 
from  a  variety  of  persistent  causes — as  continued  anxiety  of  mind, 
constant  pain,  etc. — yet  their  strength  remains  good.  Neverthe- 
less, if  such  individuals  become  weak,  the  nervous  symptoms  be- 
come more  intense.  This  principle  explains  what  degree  of  truth 
there  is  in  the  popular  belief,  that  nervous  diseases  are  caused  by 
indolence  and  self-indulgence,  and  will  disappear  if  the  mind  and 
the  body  can  be  stimulated  to  action.  "  They  can  be  worked  off." 
This  is,  indeed,  often  a  practical  truth,  but  also  a  corollary  from 
the  principle  stated,  and  is  of  great  importance  if  properly  and 
judiciously  applied.  Yet  it  should  be  remembered  that  much 
suffering  and  mischief  have  resulted  from  over-exertion  of  nerv- 
ous patients,  as  well  as  from  timidity  and  self-indulgence. 

Anjsmia. — Nervous,  hysterical  persons  are  often  very  pallid, 
emaciated,  "bloodless,"  so  called — that  is,  their  blood  is  very 
light  colored ;  there  is  a  deficiency  of  the  red  globules  or  increase 
of  the  water  of  the  blood.  There  is  ^'■ansemia'^  or  '■'•  hydrsemiar 
Hence,  in  the  minds  of  most  practitioners,  there  is  an  association 
of  anasmia  with  nervous  complaints,  so  intimate  that  the  former 
has  been  regarded  as  the  cause  of  the  latter ;  and  it  is  inferred 
that  if  the  anaemia  be  cured,  the  nervous  excitement  will  dis- 


94       NEKVOUS    IRRITATION    AND    ITS    CONSEQUENCES. 

appear.  This  conclusion  is  too  sweeping,  and  will  not  be  con- 
firmed by  experience.  The  connection  between  nervous  irrita- 
bility and  anaemia  is  not  that  of  cause  and  efi'ect,  but  that  of  a 
common  consequence  of  the  same  cause — debility.  When  there 
is  a  loss  of  power,  there  is  increased  irritability,  "nervousness." 
When  there  is  a  loss  of  power  in  the  brain  and  spinal  marrow, 
the  organic  life  suffers,  chiefly  from  the  consequent  deprivation 
of  fresh  air  and  exercise ;  hence  the  want  of  appetite  and  weak- 
ened powers  of  digestion,  of  haematosis,  of  nutrition  ;  and  thence, 
of  course,  anasmia.  If  strength  can  be  given  by  iron,  fresh  air, 
exercise,  etc.,  the  nervousness  and  also  the  anaemia  will  be  re- 
lieved. 

That  there  is  no  absolute  or  necessary  connection  between  the 
anaemia  and  nervousness,  as  cause  and  effect,  is  also  proved  by 
several  undeniable  facts.  The  important  one  is,  that  all  females  are 
comparatively  nervous,  even  with  excellent  organic  actions,  rich 
blood,  free  capillary  circulation,  rosy  complexion,  and  an  abund- 
ance of  animal  heat  continually  generated.  Their  temperament 
is  nervous.  In  some  cases,  by  no  means  few  in  number,  this  is 
wonderfully  true.  Every  one,  of  any  experience,  must  have 
known  women,  who  were  of  the  most  robust  appearance,  with 
excellent  appetite  and  digestion,  an  abundant  supply  of  blood  of 
the  purest  character,  with  all  their  functions  in  an  admirable  con- 
dition, being  strong  and  feeling  strong,  and  yet  were  excessively 
nervous,  excitable,  and  irritable.  The  least  cause,  mental  or 
physical,  will  disturb  their  sensations  or  perceptions,  and  induce 
the  worst  forms  of  hj'-steria.  Some  of  the  most  terrible  forms  of 
hysteric  convulsions,  and  of  catalepsy,  which  we  have  met  with, 
have  been  in  the  most  healthy  individuals,  as  regards  their  vege- 
table life.  They  look  well,  but  feel  supremely  wretched.  Few, 
sometimes  not  even  their  physician,  sympathize  with  them. 
They  are  regarded  as  imaginative,  or  even  as  deceitful  beings. 
The  reverse  of  the  picture  is  often  equally  true — anaemia  existing 
to  a  very  great  degree  with  few  or  no  special  manifestations  of 
nervous  irritability.  In  men,  especially,  this  is  often  the  case,  as 
in  many  cases  of  exhaustion  from  dyspepsia,  diarrhoea,  hemor- 
rhages, and  chronic  diseases.  In  women  this  is,  of  course,  not 
so  frequent,  owing  to  their  natural  temperament ;  yet  often,  in  the 
delicate,  pallid,  emaciated  woman,  you  will  discover  few  symp- 


ANJEMIA.      TOXIC^MIA.  95 

r 

toms  of  nervous  irritation,  and  you  will  hear  the  declaration, 
''Doctor,  I  have  never  been  nervous." 

The  plethoric  and  the  strong,  therefore,  may  be  very  excitable, 
the  anaemic  and  the  feeble  may  be  with  difficulty  disturbed, 
owing  to  natural  or  acquired  peculiarities ;  but  the  general  decla- 
ration is  true,  that  as  strength  is  diminished,  irritability  increases  ; 
and  the  reverse,  that  with  the  increase  of  strength  there  is  a 
diminution  of  irritability.  There  is  no  necessary  connection 
between  nervous  excitability  and  anasmia,  although  they  are 
often  conjoined. 

Toxic^MiA. — Modern  pathologists  have,  in  many  instances, 
gone  still  further,  contending  not  merely  for  a  deterioration  of 
the  vital  fluid  in  nervous  affections,  but  insisting  that  an  actual 
poison  is  frequently  present. 

From  time  immemorial  no  one  has  doubted  that  the  blood  may 
be  poisoned,  and  that  various  nervous  and  vascular  disturbances, 
followed  by  stupor,  paralysis,  and  death,  may  ensue.  We  have 
no  disposition,  therefore,  to  deny  this  fact,  nor  to  assert  that  the 
blood  may  not  be  so  corrupted  that  neuralgia,  spasms,  prostra- 
tion, etc.,  should  follow.  We  do,  however,  contend  that  these 
sources  of  irritation  are  comparatively  rare ;  and  that  in  an 
immense  majority  of  neuralgic  affections  there  is  no  trace  of 
poison  to  be  detected,  and  no  proof  of  its  influence.  The  most 
common  hypothesis  made  is,  that  urea  is  present  in  the  blood ; 
its  existence  has  been  surmised,  chiefly  by  the  fact  that  albumen 
is  detected  in  the  urine.  Hence  it  has  been  inferred  that  Bright's 
disease  of  the  kidney  or  urjemia,  one  or  both,  are  the  real  sources 
of  a  large  number  of  nervous  affections,  especially  of  convul- 
sions, during  gestation  or  parturition.  This  question  is  too  ex- 
tensive to  be  here  presented,  especially  as,  in  another  work,  we 
have  discussed  this  point  and  given  our  objections  to  the  theory 
of  uraemic  convulsions.  Suffice  it  to  say  at  this  time,  that  the 
poisoned  condition  of  the  blood  and  also  its  depuration  are  com- 
paratively slow  processes,  while  neuralgic  and  spasmodic  dis- 
eases appear  and  disappear  sometimes  with  wonderful  rapidity. 
Moreover,  it  would  seem  inevitable  so  long  as  toxicaemia  existed, 
the  nervous  affections  would  continue,  and  yet  in  practice  we  find 
that  they  often  disappear  after  a  short  existence,  while  the  fluids 
remain  unaltered ;  or,  if  they  return,  they  are  often  induced  by 
some  new  exciting  cause.     In  cases  of  puerperal  convulsions,  for 


96       NERVOUS    IRRITATION    AND    ITS    CONSEQUENCES. 

example,  pain,  straining,  disorders  of  the  stomach  or  bowels, 
mental  and  moral  agitations  will  often  excite  convulsions,  whether 
albuminuria  be  present  or  absent;  and,  if  such  irritations  be  re- 
moved, the  convulsions  cease,  and  the  patient  does  well,  notwith- 
standing the  supposed  mal-condition  of  her  blood.  The  delivery 
of  the  child  is  hailed,  therefore,  as  the  important  crisis  of  the 
disease,  after  which  the  convulsions  are  not  anticipated,  unless 
some  local  injury  has  been  sustained,  or  some  new  exciting  cause 
is  operative. 

Often  have  we  witnessed  similar  results  in  poor,  wretched, 
anaemic  women,  who  have  long  been  the  subject  of  uterine  irri- 
tation. By  removing  a  displacement,  for  example,  immediate 
relief  has  been  afforded  to  the  pains,  spasms,  dyspepsia,  and 
other  numerous  sympathetic  disturbances ;  in  a  short  period  the 
patient  feels  much  better,  appears  sometimes  to  be  rejuvenated, 
long  before  she  loses  her  pallor,  and  before  it  was  possible  for 
the  whole  circulating  fluids  to  throw  off  any  poisonous  or  dele- 
terious matter,  or  become  once  more  rich  in  red  globules,  fibrin, 
albumen,  etc. 

This  evanescent  character  of  neuralgia  and  spasms,  and  their 
curability  in  thousands  of  cases,  almost  instantaneously,  by  re- 
moving the  cause,  are  positive  proofs  that  there  is  no  poisoned 
condition  of  the  fluids  as  the  direct  source  of  mischief. 


GENERAL  CONCLUSIONS. 

We  have  thus  presented  a  general  idea  of  neurotic  or  hyste- 
rical diseases.  Precise  meanings  have  been  attached  to  many 
words  in  common  use ;  and  terms,  constantly  used  in  medical 
language,  but  usually  without  sufficient  precision,  have  been 
defined  and  explained  as  they  will  hereafter  be  employed  in  these 
pages. 

The  hysterical,  or  the  neurotic  diseases  of  women,  are  therefore 
states  of  irritation  of  the  cerebro-spinal  nervous  system  in  whole 
or  in  part.  They  are  very  evanescent  when  the  cause  is  transi- 
tory, as  in  nervous  aS'ections  from  moral  causes,  such  as  fear, 
anger,  anxiety,  joy,  grief;  or  from  physical  causes,  as  from  indi- 
gestion, flatulence,  etc. ;  but  very  persistent  in  all  cases  where 
the  cause  remains  operative,  and  will  then  often  defy  the  best 


GENERAL    COXCLUSIOXS.  97 

directed  remedial  agents  for  montlis  and  3'-ears.  Hence  tlie  indo- 
mitable character  of  various  nervous  or  neuralgic  diseases ;  the 
cause  is  persistent,  perhaps  it  has  not  been  detected,  or  cannot  be 
removed.  Tonics,  nutritious  diet,  exercise,  travelling,  as  well  as 
antispasmodics,  narcotics,  and  stimuli,  prove  useless,  or  perhaps 
worse  than  unless,  and  at  best  are  but  temporary  palliatives.  The 
symptoms  will  return,  often  with  increased  vehemence.  The 
location  of  the  cause  may  be  in  any  tissue  or  organ  of  the  body. 
Wherever  the  irritability  or  sensibility  of  a  part  is  disturbed, 
thence,  as  from  a  focus,  may  radiate  nervous  excitements.  They 
are  usually  perceived  in  the  nerves  involved,  first  at  the  point 
irritated ;  then,  if  sufiiciently  severe,  in  the  sentient  extremities 
of  such  nerves,  or  in  the  reverse  direction  towards  their  origin 
in  the  spinal  marrow  or  the  brain,  and  thence  again  by  reflex 
influences  in  any  tissues  of  the  economy ;  thus  causing  a  disturb- 
ance of  the  functions  of  such  tissues  or  organs,  so  far  as  these 
functions  are  dependent  on  nervous  influences.  In  other  words, 
"nervous  irritations"  of  the  brain  and  spinal  axis,  and  of  their 
dependencies,  may,  and  often  do,  arise  from  any  local  irritation. 
It  is  often  of  small  consequence  what  may  be  the  character  of 
such  local  irritation,  whether  it  be  simply  nervous  or  inflamma- 
tory, S3mipathetic  nervous  irritations  may  result  in  different  and 
often  in  very  distant  portions  of  the  animal  economy. 

Odontalgia  and  otalgia  often  excite  neuralgic  pains  and  spasms 
of  the  nerves  and  muscles  of  the  face  and  neck,  and  sometimes 
severe  headaches,  and  other  cerebral  disturbances.  Often  croup, 
asthma,  and  palpitations  of  the  heart,  as  well  as  gastrodynia  and 
colics,  are  excited  by  indigestion ;  and  by  the  same  cause  head- 
aches, delirium,  and  convulsions,  are  very  frequently  induced. 
Hysteric  convulsions  and  epileptic  spasms,  as  well  as  the  more 
dangerous  tetanic  affections,  are  constantly  excited  by  the  pre- 
sence of  a  thorn  in  the  flesh,  by  a  local,  painful  inflammation, 
or  other  organic  irritations.  The  proof  seems  positive  to  the 
medical  philosopher,  not  merely  that  such  nervous  disturbances 
follow  local  irritations,  but  that  they  disappear  almost  instanta- 
neously on  the  removal  of  such  affections,  while  they  remain 
obstinate  under  the  best  general  treatment  if  the  local  irritation 
be  allowed  to  continue.  The  continuity  of  tissue,  and  the 
wonderful  unity  of  the  nervous  system,  together  with  the  incon- 
ceivable rapidity  by  which  impressions  are  transmitted  in  health 
7 


98       NERVOUS    IRRITATION    AND    ITS    CONSEQUENCES. 

from  the  circumference  to  the  centres,  and  from  the  centres  to 
the  circumference,  aft'ord  a  most  satisfactory  explanation  of  the 
transmission  of  such  morbid  irritations,  and  of  their  reflex 
influence  to  distant  parts,  or  to  the  whole  of  the  cerebro-spinal 
apparatus. 

A  complete  history  of  nervous  disease  would  involve,  therefore, 
an  account,  if  it  were  possible,  of  the  innumerable  causes,  whether 
intellectual,  moral,  or  physical,  which  may  disturb  the  sentient 
system.  The  nervous  and  cerebral  symptoms  being,  after  all,  not 
strictly  the  disease,  but  the  indices — as  they  are  the  results  of  the 
primary  impressions  of  the  local  irritation.  Such  a  task  would 
be  endless,  and  in  a  great  degree  fruitless.  Our  object  is  far  more 
humble  and  limited.  It  is  to  illustrate  the  general  truths  already 
enunciated,  by  a  detailed  account  of  those  nervous  disturbances 
which  are  excited,  or  kept  up  by  the  uterus  and  its  appendages 
when  in  a  state  of  morbid  irritation,  and  hence  to  deduce  ihe 
proper  pathology  and  therapeutics  of  irritable  diseases  in  women. 

The  general  principles  applicable  to  all  the  variety  of  neurotic 
complaints  will,  it  is  trusted,  be  thus  evolved  and  elucidated, 
inasmuch  as  no  organ  of  the  body  has  so  constant  and  direct  an 
intercommunion  with  the  nervous  system  as  the  uterus ;  and 
inasmuch,  also,  as  the  peculiar  physiological  and  pathological 
character  of  the  female  sex  is  most  intimately  and  indissolubly 
connected  with  this  organ  and  its  appendages. 


IRRITABLE    UTERUS.  99 


CHAPTER    II. 

IRRITABLE    UTERUS. 

What  idea  is  to  be  associated  with  the  expression,  "  an  irritable 
"Uterus?"  No  other  than  that  the  organ  is  more  sensitive — more 
easily  excited — than  when  in  a  healthy  state.  It  is  no  longer  in 
a  normal  condition,  but  in  an  abnormal,  unhealthy,  diseased  state. 
This  diseased  condition  has  reference,  let  it  be  observed,  not  to 
its  circulatory  system,  and,  of  course,  not  to  its  organic  life,  but 
to  its  nervous  system,  its  animal  life.  It  is  a  state  not  of  organic 
irritation,  but  of  nervous  irritation.  In  simple  uncomplicated 
cases,  the  alteration  of  the  sensibility  is  the  only  indication  of  its 
existence.  There  is  necessarily  no  turgescence  of  the  organ,  no 
congestion,  active  or  passive,  no  inflammation,  and,  of  course,  no 
alteration  of  structure  in  an  irritable  uterus,  even  after  the  lapse 
of  years.  Congestions  and  inflammations,  when  found,  are  com- 
plications, sometimes  the  result  of  the  nervous  excitement  of  the 
organ,  but  frequently  adventitious  and  secondary,  or  accidental. 

In  a  normal  state  the  uterus,  although  abundantly  supplied 
with  nerves,  and  capable  of  being  readily  excited,  has  very  little 
sensibility.  It  can  be  pressed  upon  and  pushed  in  various  direc- 
tions, almost  without  the  consciousness  of  the  woman ;  but,  from 
various  causes,  this  quiescent  condition  of  its  animal  life  may  be 
disturbed.  Its  vitality  is  exalted,  it  becomes  more  excitable; 
slight  impressions  cause  sensation,  pain,  even  severe  pain,  spasms, 
cramps,  and  other  evidences  of  nervous  irritation,  of  morbid 
excitement.  It  has  passed  from  a  healthy  to  an  unhealthy  state, 
as  regards  its  nervous  system ;  it  is  morbidly  sensitive ;  it  is 
"  irritable."  This  state  is  a  simple  exaltation  of  a  natural  vital 
property,  sensibility,  and  constitutes  a  nervous  irritability  beyond 
its  normal  or  healthy  standard.  The  organic  actions,  everything 
relating  to  the  circulation,  nutrition,  growth,  alteration  of  struc- 
ture, etc.,  are  not  necessarily  affected,  and  very  often  not  in  any 
appreciable  degree  disturbed,  even  after  the  lapse  of  years,  though 


100  IRRITABLE    UTERUS. 

many  painful  and  distressing  symptoms  may  have  unremittingly 
existed. 

This  is  no  novel  emjoloyment  of  the  word  "  irriicible^''  but  is  in 
accordance  with  the  common  language  of  physicians,  whatever 
opinions  they  may  have  adopted  on  medical  subjects.  Every  one 
is  familiar  with  its  use  in  physiology,  especially  since  the  time  of 
Haller.  Irritability  has  often  been  regarded  as  the  only  vital 
property  of  organized  tissues,  and  by  most  writers  as  having 
respect  merely  to  organic  life ;  while  many  have  restricted  it  to 
particular  tissues,  and  some  even  to  a  single  tissue,  maintaining 
that  there  is  no  irritability  without  contraction.  Modern  patho- 
logists have  been  driven  to  its  use,  in  speculating  on  the  morbid 
states  of  the.  tissues — however  indefinite  and  irregular  may  have 
been  their  employment  of  the  word.  We  are,  perhaps,  chiefly 
indebted  to  Mr.  Brodie  for  its  introduction  into  pathology.  In 
his  admirable  work  on  the  diseases  of  joints,  he  specified  many 
cases  of  very  painful  affections,  in  which  observation  and  expe- 
rience proved  that  there  was  no  inflammatory  action,  and  no  dis- 
organization of  tissue.  "A  morbid  condition,"  he  says,  "which 
may  be  regarded  as  a  local  hysteric  affection."  This  hysteric  or 
nervous  state  he  described  as  existing  not  only  in  joints,  but  in 
various  other  tissues,  particularly  in  the  female  mammse ;  hence 
we  have  read  of  "  irritable  joints,"  "  irritable  mammge,"  etc.  Sir 
Astley  Cooper  authorizes  the  same  use  of  the  word,  and  speaks 
of  "  irritation"  as  distinct  from  inflammation.  To  Dr.  Gooch  we 
are,  however,  chiefly  indebted  for  the  exact  definition  of  this  word, 
and  its  application  to  uterine  pathology,  in  his  most  admirable 
essay  on  "Irritable  Uterus."  He  designates  it  as  a  "painful  and 
tender  state  of  this  organ — neither  attended  by  nor  tending  to 
produce  change  in  its  structure."  In  some  cases,  after  the  lapse 
of  ten  years  of  sufi'ering,  no  alteration  of  structure  could  be  de- 
tected by  him.  The  disease,  he  says,  is  very  obstinate,  and  very 
slightly  under  the  influence  of  remedial  agents  ;  but  nevertheless, 
in  time,  patients  often  perfectly  recover,  although  relapses  are 
very  apt  to  occur  from  the  slightest  cause.  Dr.  Dewees,  of  the 
University  of  Pennsylvania,  deserves  notice,  in  this  connection, 
as  having  fixed  the  attention  of  the  American  profession  on  this 
complaint  in  an  excellent  essay ;  although  he,  like  most  patholo- 
gists, wandered  from  the  simple  idea  of  an  irritable,  to  that  of  an 
inflamed  organ.     lie  unfortunately  intimates  that  it  is  analogous 


BRODIE,    GOOCH,    DEWEES.  101 

to  a  "sort  of  iuflammatory  state:"  and  still  more  unfortunately, 
both  he  and  Dr.  Gooch,  and,  indeed,  nearly  all  physicians,  have 
practically,  if  not  theoretically,  adhered  to  the  same  idea ;  pur- 
suing, more  or  less  decidedly,  the  antiphlogistic  treatment,  in 
opposition  to  that  which  experience  as  well  as  a  more  correct 
pathology  would  indicate. 

Supposed  Difficulty  of  Treatment. — Notwithstanding  the  light 
which  has  been  thrown  upon  pathology  by  the  discoveries  of  the 
anatomists  and  the  chemists,  by  laborious,  minute,  and  careful 
observation  at  the  bedside  of  the  patient,  and  by  the  results  of 
post-mortem  examinations ;  yet  during  the  last  few  years  very 
slight  advance  has  been  made,  theoretically  or  practically,  over 
the  doctrines  of  the  late  Dr.  Gooch,  in  his  excellent  monograph 
already  referred  to.  Most  practitioners  have  been  forced  to  con- 
fess that  irritable  uterus  is  "very  obstinate  and  intractable,"  and 
that  "no  disease  is  so  liable  to  relapse;"  although,  "  in  time,"  years 
of  suffering  having  passed  away,  "  in  most  cases,  a  perfect  re- 
covery may  be  expected."  Hence  diseases  of  women,  especially 
those  implicating  the  uterine  system,  have  been  regarded  as  having 
something  mysterious  or  peculiar  in  their  nature,  and  so  difficult 
to  manage  as  to  deter  many  from  their  investigation,  and  to  excite 
in  the  minds  of  all,  a  doubt,  whether  such  diseases  can  be  readily 
and  successfully  treated.  Discrepancies  of  opinion,  among  patho- 
logists and  practitioners,  have  therefore  been  exceedingly  great 
upon  this  subject;  and  it  is  mortifying,  to  the  lover  of  medical 
science,  to  notice  these  diversities  of  sentiment  in  the  various 
periodicals ;  and  the  discussions — not  always  in  the  best  temper 
— to  which  they  have  given  origin,  in  the  most  learned  bodies  of 
Europe  and  America.  These  modifications  of  views,  influencing 
more  or  less  the  practice  of  physicians,  have  given  origin  to 
various  expressions  used  to  designate  the  morbid  state  of  the  pa 
tient ;  and  thus,  far  too  often,  has  attention  been  riveted  on  organs, 
as  primarily  and  essentially  diseased,  which  are  remote  from  the 
real  source  of  mischief.  Very  often  have  diseases  of  the  uteras 
been  referred  to  the  ovaries,  to  the  kidneys,  to  the  liver,  heart, 
lungs,  spinal  marrow,  and  even  to  the  brain ! 

Neuralgia^  Hysteralgia^  etc. — The  idea  of  an  irritable  organ  has 
been  embodied  under  the  names  of  neuralgia,  tic  douloureux,  a 
neuralgic  state ;  hence  we  read  of  odontalgia,  otalgia,  cephalalgia, 
spinal gia,  hysteralgia,  etc.    To  these  expressions  there  is  no  objec- 


102  IRRITABLE    UTERUS 

tion  when  reference  is  made  to  nervous  irritation  as  accompanied 
bj  pain :  but  they  do  not  embrace  those  innumerable  varieties  of 
nervous  irritation,  in  which  there  is  no  pain  whatever ;  neither 
do  they  answer  as  a  substitute  for  the  word  "irritable"  or  "ex- 
citable," which  has  reference  to  the  quiescent  condition  of  the 
tissue,  to  its  capability  of  being  readily  excited,  when  no  actual 
excitement  or  irritation  is  present.  It  is  irritable,  but  it  may  not 
be  irritated,  or  excited ;  it  is  in  a  passive,  not  an  active  state. 
There  is  no  neuralgia,  no  nervous  irritation,  when  the  irritant, 
the  exciting  cause,  is  absent.  If  an  irritant,  sometimes  even  the 
most  trifling,  be  applied,  nervous  irritation  in  some  form  is 
excited  ;  occasionally  as  pain,  then,  and  then  only,  to  be  termed 
neuralgia.  This  self-evident  distinction  between  irritability  and 
neuralgia  is  of  great  importance.  A  patient  will  often  exclaim, 
"  I  am  perfectly  well  this  morning,  do  permit  me  to  rise  from  my 
couch."  If  permission  is  granted,  pain,  spasms,  even  convulsions, 
may  be  the  consequence.  In  this  case,  the  patient,  at  rest,  has 
not  a  morbid  sensation,  yet  her  nervous  system  is  in  a  state  of 
great  excitability ;  the  least  motion  produces  irritation,  nervous 
excitement. 

Irritable  Diseases  really  Physical  Ailments. — Many  of  these  irri- 
table states  of  the  cerebro-spinal  nervous  system  are  so  peculiar, 
so  intimately  involved  with  the  mental  and  moral  affections 
(whose  manifestations,  be  it  remembered,  are  through  the  medium 
of  the  brain  as  their  instrument),  and,  at  the  same  time,  so  com- 
patible with  the  integrity,  and  even  perfect  development  of  the 
organic  functions,  that  superficial  pathologists  have  no  faith  in 
their  existence.  With  such  and  with  many,  very  many,  (^ut  of 
the  profession,  hysteria  is  an  idea,  "ei  prseterea  nihil,^^  a  notion  ;  it 
is  mental,  not  physical.  Even  when  evidently  associated  with  the 
uterus,  and  accompanied  by  pain,  it  is  said  to  arise  from  timidity, 
from  the  remembrance  of  past  evils,  and  is  termed  a  "pseudo-pro- 
lapsus." In  the  opinion  of  such  pathologists,  these  patients,  in- 
stead of  being  forced  to  keep  the  recumbent  position  month  after 
month,  and  year  after  year,  could,  if  they  pleased,  walk  miles 
with  impunity. 

Perhaps  it  may  be  asserted,  that  many  of  the  leading  authori- 
ties of  the  day  do  not  acknowledge  the  distinction  now  drawn 
between  irritable  diseases  and  those  of  the  vascular  system ;  and 
do  not  recognize  the  great  differences  in  theory  and  practice,  be- 


OPIXIOXS    OF    PATHOLOGISTS.  103 

tween  the  disturbances  of  tlie  animal  and  the  organic  actions. 
Hence,  general  nervous  affections  are  always  associated  in  their 
minds  with  congestion  or  inflammatory  states  of  the  brain,  or 
spinal  marrow  :  and  all  these  local  affections  of  the  uterus  are 
noticed  and  treated  under  the  names  of  congestion  or  engorge- 
ment ;  of  inflammation,  acute  or  chronic ;  of  rheumatic  or  gouty 
irritations ;  of  sub-inflammations  of  the  neck  or  body  of  the 
uterus ;  of  the  os  tincge ;  of  the  lining  membrane  of  the  cavity  of 
the  neck  ;  of  the  vagina ;  of  the  bladder  ;  of  the  urethra  ;  of  the 
rectum ;  of  the  ovaries,  etc.  No  nervous  irritation  is  regarded 
as  an  original  affection,  but  always  as  the  result  of  organic 
disturbance.  However, the  actual  separate  existence  of  purely 
nervous  diseases,  and  the  importance  of  distinguishing  between 
nervous  and  vascular  affections,  between  nervous  and  inflamma- 
tory complaints,  are  daily  becoming  more  and  more  realized  by 
physicians  and  surgeons ;  so  that  diseases  formerly  indomitable, 
under  every  variety  of  a  decided  antiphlogistic  treatment,  readily 
disappear  when  treated  as  nervous,  irritable,  or  neuralgic  affec- 
tions. Medical  men  are  now  continually  speaking  of  irritable 
stomach,  bowels,  larynx,  lungs,  heart,  bladder,  and  urethra,  as 
well  as  of  irritable  joints,  mammae,  muscles,  brain,  and  nerves.^ 
There  are  few  practitioners  who  have  not  met  with  cases  of  irri- 
table condition  of  the  eyes,  often  as  an  original  affection,  and 
sometimes  as  the  result  (here,  as  in  other  cases)  of  inflammatory 
complaints ;  and  which  for  days,  months,  and  years,  have  inca- 
pacitated the  patient  from  the  ordinary  duties  of  life,  yet,  to  the 
best  observers,  manifesting  no  symptoms  of  congestion  or  inflam- 
mation. This  is  a  state  in  which  evacuant  remedies  rather  ag- 
gravate than  relieve,  and  will  often  continue  for  years  without 
apparent  change ;  and  then  disappear  gradually,  or  suddenly, 
leaving  no  vestige  of  its  power,  or  existence,  no  alteration  of 
structure,  and  no  imperfection  of  vision. 

Irritable  affections,  "  nervous  irritations,"  have,  therefore,  a 
veritable  existence  ;  they  have  a  local  habitation ;  they  are  physi- 
cal, not  moral  disturbances;  real,  not  imaginary  diseases.  They 
demand  attention  by  physical  as  well  as  by  moral  means,  and 
should,  therefore,  receive  unremitting  attention ;  although  a  late 

'  Hence  the  words  "  vagiuisinus,"  "  laryngismus,"  "  sphincterismus,"  etc. 


10-i  IRRITABLE    UTERUS. 

writer  has  considered  them  as  the  ''  scape-goat  of  modern  patho- 
logists." 

All  Pain  is  Nervous. — As  a  corollary  from  the  above  observa- 
tions it  may  be  stated  that  pain  is  not  necessarily  connected,  as 
before  mentioned,  either  with  nervous  or  inflammatory  diseases. 
There  may  be  a  vast  degree  of  nervous  distress;  of  miserable, 
wretched,  indescribable,  and  tormenting  sensations;  of  spasms 
and  convulsions,  without  any  pain  whatever.  So,  also,  every 
practitioner  is  aware  that  inflammations,  sometimes  even  the 
acute  variety,  may  exist  in  almost  all  the  tissues  of  the  body 
(nerves,  perhaps,  excepted),  with  little  or  no  pain.  Often  inflam- 
mations of  the  viscera,  heart,  lungs,  liver,  and  kidneys,  of  all  the 
mucous  membranes,  of  the  subcutaneous  tissue,  and  even  of  the 
serous  and  muscular  tissues,  have  existed  and  progressed  to  sup- 
puration, ulceration,  and  gangrene,  without  their  existence  being 
indicated  to  the  patient  by  any  painful  sensations.  Pain  is  not 
necessary  to  inflammatory  action;  it  is  not  essential,  it  is  acci- 
dental. Moreover,  pain  is  far  more  common  and  more  severe  in 
nervous  than  in  inflammatory  disease.  He  who  is  experiencing 
severe  odontalgia,  otalgia,  cephalalgia,  or  the  agonizing  suffer- 
ings of  some  forms  of  neuralgia  of  the  extremities,  or  of  gastro- 
dynia,  colics,  and  other  spasmodic  diseases,  would  willingly 
exchange  them  for  the  pains  of  phlegmonous  or  febrile  affections. 
The  truth  is,  that  all  pain  is  nervous,  it  is  neuralgic,  an  irritation 
of  the  nerves  of  sensation;  and,  therefore,  it  never  occurs  as  a 
symptom  of  disease  unless  the  nerves  of  sensation  be  involved, 
directly  or  indirectly,  in  the  part  diseased.  Nearly  all  diseases 
may  exist  without  pain,  and  severe  suffering  is  comparatively 
rare  in  the  most  destructive  and  fatal  forms  of  morbid  excite- 
ment. 

These  observations  are  strictly  applicable  to  all  the  varieties 
of  morbid  affections  in  women,  but  especially  to  irritations  of 
their  pelvic  viscera.  Hence,  they  are  often  great  sufferers,  mar- 
tyrs to  agonizing  pain,  and  may  be  tormented,  even  for  years, 
with  neuralgic  and  spasmodic  affections,  without  serious  injury 
to  their  organic  actions  or  to  their  lives.  Proofs  of  this  will 
appear  in  a  review  of  the  symptoms,  progress,  and  consequences 
of  irritable  uterus. 


PAIN    AXD    DISTRESSING    SENSATIONS.  105 


CHAPTER    III. 

LOCAL    SYMPTOMS    OF  IRRITABLE    UTERUS. 

The  local  symptoms  embrace,  not  only  those  tliat  depend  directly 
on  the  uterus,  but  also  those  that  involve,  more  or  less,  all  the 
viscera  and  the  surrounding  tissues  (as  the  muscles,  nerves,  etc. 
of  the  pelvis. 

PAO   AND  DISTRESSING  SENSATIONS. 

Among  the  local  symptoms,  pai7i  is  by  far  the  most  frequent ; 
and  often,  to  the  patient,  the  only  indication  of  disorder.  Usually 
it  is  felt  in  the  upper  portion  of  the  sacral  region,  occasionally  in 
the  hypogastrium  directly  above  the  pubis,  sometimes  in  the 
pubis.  Ladies  often  speak  of  the  pain  in  the  "side,"  by  which 
they  generally  mean  the  region  of  the  abdominal  canal,  through 
which  passes  the  round  ligament  ("  ligamentum  rotundum").  It 
is  a  singular  fact  that  this  pain  is  seldom  felt  by  the  same  patient 
upon  both  sides,  but  almost  always  on  one  side  only,  even  when 
it  continues  for  a  series  of  years.  Often  it  is  felt  higher  up,  in 
the  region  of  the  caecum  or  of  the  sigmoid  curve  of  the  colon.  It 
is  not  always  constant,  but  depends  on  various  exciting  causes ; 
nevertheless  it  is  manifested  in  the  same  individual,  generally  in 
the  same  place.  Many  patients  refer  the  suffering  to  the  interior 
of  the  body,  to  the  womb  directly ;  some,  who  think  themselves 
wise,  to  the  neck  of  the  uterus,  to  the  vagina,  the  rectum,  the 
vulva,  or  the  bladder.  Often  it  is  felt  in  one  or  both  hips,  some- 
times as  if  in  the  joint  itself.  Perhaps  the  pain  is  usually  expe- 
rienced, not  in  one  point  only,  but  in  several  at  the  same  time, 
as  in  labor;  extending  from  the  back  completely  around  to  the 
groins,  the  hypogastric  region,  and  down  the  thighs.  It  is 
often  very  trifling,  sometimes  very  severe  and  agonizing,  pre- 


106  LOCAL    SYMPTOMS    OF    IRRITABLE    UTERUS. 

venting  all  comfort  while  in  motion,  and  often  continuing  even 
"vvlien  the  sufferer  is  at  rest  in  the  recumbent  position. 

The  hind  of  pain  varies  indefinitely;  and  various  expressions 
are  employed  to  give  an  idea  of  its  character.  Perhaps  most  fre- 
quently, it  is  described  as  a  dull,  aching,  weary  feeling  in  the  back, 
with  more  or  less  of  a  sense  of  pressure,  weight,  dead  feeling, 
heaviness,  fatigue,  or  debility.  Not  unfrequently,  in  the  abdomen, 
it  is  a  sore  pain,  a  sharp  needle-like  or  lancinating  pain.  With 
some,  it  is  mere  soreness;  and  in  very  many,  after  the  acute  cha- 
racter has  subsided,  soreness  remains  often  so  great  that  the  weight 
of  the  bedclothes  becomes  troublesome.  In  the  hips  and  down 
the  limbs,  there  is  often  the  same  weary  and  dull  pain  with  a  sense 
of  fatigue  and  an  inability  to  move;  but  sometimes  it  is  sharp, 
neuralgic,  "  toothache-like,"  and  occasionally  excites  spasmodic 
and  painful  action  of  the  muscles  of  the  hips,  thighs,  etc.  The 
sensations  are  often  j^ulsatile,  resembling  those  preceding  or  accom- 
panying the  suppurative  stage  of  inflammation.  This  beating, 
"  strumming,"  vibrating  pain  is  referred  to  the  womb,  vagina, 
bladder,  rectum,  etc.,  and  is  often  very  tormenting.  A  burning 
sensation,  or  feelings  of  moderate  or  severe  degrees  of  heat,  are 
not  uncommon  in  the  vagina,  the  vulva,  urethra,  sometimes  in 
the  sacral  or  the  hypogastric  regions,  over  the  whole  lower  part 
of  the  abdomen,  and  extending  to  all  the  anterior  portions  of  the 
thighs.  This  is  very  distressing,  and  sometimes  so  severe  that 
patients  have  declared  the  burning  could  not  be  greater  were  they 
to  stand  perfectly  exposed  before  a  hot  fire,  or  if  coals  of  fire  were 
placed  within  them. 

In  addition  to  pain,  and  very  frequently  when  there  is  no  pain 
whatever,  there  are  numerous  se7isations  more  or  less  distressing, 
indicating  an  irritable  state  of  the  uterus  and  the  adjacent  organs. 
Some  of  these  are  very  common,  as  sensations  of  weakness,  de- 
bility, languor,  often  with  feelings  of  fulness,  pressure,  weight ; 
a  "  bearing-down"  sensation  in  the  back,  abdomen,  thighs,  in  the 
lower  part  of  the  pelvis,  in  the  bladder,  vagina,  rectum ;  an  "open, 
feeling,"  as  if  there  was  no  support,  and  all  the  pelvic  contents 
must  escape,  or  as  if  the  patient  would  "fall  in  pieces"  when  in 
the  erect  position ;  a  sense  of  pressure  on  the  rectum,  as  if  the 
bowels  must  be  moved,  or  simulating  the  fulness  and  weight  of 
hemorrhoidal  tumors.  A  great  sensation  of  distress,  of  prostra- 
tion, often  exists  after  the  bowels  have  been  moved.     Similar 


VARIETIES    OF    PAIN".  107 

troubles  are  also  experienced  about  the  neck  of  the  bladder,  and 
the  urethra,  especially  at  its  orifice,  with  frequent,  sometimes 
almost  constant,  inclination  to  urinate,  and  then  a  burning,  scald- 
ing sensation.  There  is  often  an  indomitable  disposition  to  mic- 
turate, even  continuing  for  half  an  hour  or  an  hour  without  inter- 
mission, only  a  few  drops  of  urine,  perfectly  natural  in  its  cha- 
racter, being  voided.  These  and  other  symptoms  of  dysuria  are 
sometimes  so  great,  that  violent,  agonizing  pain  and  spasms  of  the 
bladder  ensue,  as  in  the  worst  forms  of  cystitis ;  yet  no  stone,  no 
gravel,  no  morbid  secretions  from  the  bladder  or  the  kidneys,  can 
be  detected.  This  uneasiness  and  distress  at  the  orifice  of  the 
urethra,  or  throughout  its  course,  with  more  or  less  sensations  of 
heat  and  fulness,  are  often  confounded  with  the  symptoms  of  in- 
flammatory action. 

These  miserable  feelings  are  often  extended  to  the  sphincters  of 
the  bladder,  vagina,  and  the  rectum,  with  sensations  of  painful 
contractions  or  spasms,  including  even  the  muscular  coats  of  the 
vagina  or  rectum,  and  the  levatores  ani  muscles. 

Distress  and  pain  are  often  evidently  connected  with  the  pudic 
and  obturator  nerves,  and  with  all  the  complicated  sacro-ischiatic 
plexuses.  These  may  be  comprehended  under  the  general  head 
of  "  sacral  irritation,"  to  which  reference  will  hereafter  be  fre- 
quently made  in  this  work,  when  treating  of  displacement  of  the 
uterus,  with  which  all  these  complaints  are  intimately  connected. 

These  morbid  sensations  vary  exceedingly  in  different  cases. 
In  some  they  are  so  trifling  that  the  patients  will  hardly  acknow- 
ledge the  existence  of  any  disease;  in  others  so  severe  that  life 
has  no  charms — death  is  regarded  as  a  blessing,  and  the  only 
refuge  from  persisting  and  inevitable  agony. 

Aggravated  by  Motion. — In  decided  cases  of  irritable  uterus, 
however,  patients  are  often  very  comfortable  as  long  as  no  exciting 
cause  is  present.  Hence,  when  perfectly  at  rest,  they  can  hardly 
realize  that  they  have  any  trouble  whatever ;  but  the  least  mental 
or  corporeal  excitement  will  disturb  the  sensibilities,  and  too 
surely  indicate  the  locality  and  the  nature  of  their  complaints. 
The  mere  erect  position  usually  induces  pain  or  distress,  and 
every  attempt  to  walk  is  followed  by  great  suffering.  In  others 
the  patients  can  walk  moderate  distances,  but  afterwards  suffer 
for  hours,  or  even  days.  Generally,  after  walking,  pain  is  expe- 
rienced.    Nothing  troubles  such  individuals  so  much  as  ascendiuof 


108  LOCAL    SYMPTOMS    OF    IRRITABLE    UTERUS. 

hills,  stairs,  or  attempting  to  lift  weights.  The  fact  is,  that  any 
and  all  muscular  exertion  induces  pain;  as  such  exertion  can 
hardly  be  made  without  interesting,  more  or  less,  the  abdominal 
muscles  and  diaphragm,  so  that  pressure  is  made,  by  means  of  the 
superincumbent  viscera,  directly  on  the  uterus :  and,  in  its  irri- 
table state,  the  least  pressure  is  felt.  Hence  any  exertion,  even 
of  the  upper  extremities,  in  holding  a  book,  in  sewing,  in  combing 
the  hair,  is  intolerable.  Few  patients  can  bear  to  stand  erect ; 
all  can  walk  more  readily  than  they  can  stand  still.  To  stoop  low 
is  very  difficult ;  even  slightly  bending  the  body  forward,  as  over 
a  table,  is  annoying. 

In  the  sitting  posture,  it  is  an  effort  to  keep  the  body  erect;  a 
forward  inclination  is  usually  preferred.  The  continuance  of  this 
position  for  any  length  of  time  is  followed  by  feelings  of  languor, 
lassitude,  and  by  aching,  and  painful  sensations.  At  the  moment 
of  sitting  down,  in  some  cases,  there  is  at  once  a  darting  pain,  or 
pain  soon  follows  this  act ;  so  that  patients  have  often  to  sit  on  a 
ring-pillow,  or  on  one  of  their  feet  adroitly  twisted  underneath 
them.  This  doubtless  arises  from  pain  being  felt,  when  the  peri- 
neum is  pressed  upward  against  the  tender,  sensitive  uterus. 

Sneezing,  coughing,  and  vomiting  are  often  intolerable ;  even  a 
deep  inspiration,  the  distension  of  the  abdomen  (of  the  stomach 
and  bowels,  but  especially  of  the  ctecum  and  of  the  sigmoid  por- 
tion of  the  colon)  by  food,  fasces,  or  gas,  are  sources  of  discomfort, 
and  even  of  positive  pain.  The  natural  effort  to  empty  the  blad- 
der often  induces  pain,  when  it  is  not  perceived  at  other  times ; 
or  aggravates  the  terrible  dysuria  that  so  frequently  exists  with 
irritable  uterus.  The  pain  of  defecation,  already  noticed,  is  ex- 
ceedingly enhanced  by  the  bearing-down  efforts  which  costive- 
ness,  and  the  sensations  of  fulness,  pressure,  and  weight  in  the 
sacral  region,  so  often  excite.  The  mere  pressure  of  masses  of 
faeces,  collected  in  the  rectum,  excites  pain;  and  this  is  terribly 
aggravated  by  their  transit  under  the  influence  of  the  muscular 
action  of  the  rectum  and  the  straining  efforts  of  the  abdominal 
muscles.  So  great  is  the  suffering  induced  that  such  efforts  are 
sometimes  unbearable ;  the  feculent  matter  is  retained  until  forced 
out  by  purgative  medicines,  or  removed  by  the  surgeon.  Often 
have  patients  declared,  that  martyrdom  would  be  preferable  to 
such  agony.  In  some  cases  of  prolonged  constipation,  the  pro- 
cess of  defecation  simulates  a  tedious  and  severe  case  of  parturi. 


SIMPLE    DYSMENORRHCEA.  109 

tion.  For  similar  reasons,  enemata,  even  of  water  or  mucilage, 
are  most  distressing ;  suffering  being  excited  by  even  a  small 
quantity  of  fluid  thrown  into  the  rectum.  In  many  cases,  even 
where  no  pain  is  experienced,  there  follow  a  great  sense  of  weak- 
ness and  exhaustion  after  defecation,  and  often  a  feeling  of  un- 
easiness, or  tenesmus,  as  if  the  rectum  was  still  unemptied. 
These  sensations  of  distress  and  of  pain  in  the  rectum  are  often- 
times transmitted  to  the  posterior  perineum,  the  regions  of  the 
coccyx  and  sacrum,  and  thence  down  the  thighs. 

In  these  irritable  states  of  the  iiterus,  vagina,  etc.,  where  the 
least  pressure  excites  pain,  coition  becomes  a  source  of  great  suf- 
fering, and  is  sometimes  actually  intolerable.  The  pain  at  the 
vulva  is  often  excessive,  although  sometimes  pain  is  not  experi- 
enced until  the  uterus  is  touched.  This  is  often  a  source  of  not 
onl}^  physical,  but  great  mental  and  moral  distress.  Pregnancy 
is  not  apt  to  occur ;  when  it  does  ensue,  the  organic  and  other 
changes  in  the  uterus  not  unfrequently  produce  a  favorable  revo- 
lution: but,  very  generally,  the  irritability  of  the  womb  causes 
much  sufiering  during  the  whole  period.  Sometimes  contractile 
pains  and  abortions  result;  or,  if  gestation  continues,  the  slightest 
motion  of  the  foetus  in  utero  becomes  truly  annoying.  Parturi- 
tion is  more  severe,  the  after-pains  are  more  common  and  more 
intense.  These  pains  are  occasionally  so  persistent,  and  accom- 
panied with  so  much  soreness  on  pressure,  and  on  motion,  as  to 
simulate  very  exactly  the  phenomena  of  peritonitis  or  other 
varieties  of  puerperal  inflammations.  After  delivery,  frequently, 
all  the  symptoms  of  irritable  uterus  are  re-excited,  in  full  force, 
on  the  patient's  return  to  her  usual  avocations.  In  other  cases, 
complete  recoveries  are  effected  by  the  revolutions  induced  by 
pregnancy  and  lactation. 

Aggravated  by  Menstruation. — Of  course,  the  symptoms 
of  irritable  uterus  are  aggravated  by  any  and  every  cause,  mental, 
moral,  or  physical,  which  directly  or  indirectly  stimulates  the 
uterus  or  its  appendages.  Menstruation,  therefore,  usually  aggra- 
vates the  phenomena,  sometimes  to  an  intense  degree. 

Simple  Dysmenorrhoea. — The  normal  nervous  excitement  of 
these  periodical  returns  becomes  inordinate,  abnormal,  and  exces- 
sive, constituting  that  morbid  state  known  as  Dysmenorrhoea. 
Irritability  of  the  uterus  is,  very  universally,  the  predisposing 
cause  or  condition  of  painful  or  difficult  menstruation ;  and,  of 


110  LOCAL    SYMPTOMS    OF    IRRITABLE    UTERUS. 

course,  dysmenorrhcea  is  strictly  a  symptom  of  irritable  uterus. 
This  is  the  simple  uncomplicated  form  of  dysmenorrhcea,  often 
called  "nervous"  or  "neuralgic."  Of  course,  if,  in  addition  to 
this  natural  periodic  excitement,  other  causes  be  operative  (such 
as  exposure  to  cold,  gouty,  or  rheumatic  irritations,  passions  and 
affections  of  the  mind,  sympathetic  irritations  of  other  organs, 
etc.),  the  sufferings  of  the  patient  will  be  more  or  less  aggra- 
vated. 

Few  subjects  have  excited  more  discrepancy  of  opinion  and  dis- 
cordant views  than  that  of  the  pathology  of  dysmenorrhcea.  That 
it  is  essentially  a  neuralgic  and  spasmodic  affection,  depending  on 
a  morbid  sensitive  state  of  the  tissues  involved,  is,  we  think,  the 
logical  deduction  from  all  the  phenomena  previoiis  to,  during  the 
time  of,  and  subsequent  to,  the  menstrual  period.  They  are  evi- 
dences of  nervous,  not  of  inflammatory  irritation. 

The  premonitory  symptoms  are  those  merely  of  irritable  ute- 
rus. The  sensations  of  fulness  and  weight,  the  bearing-down  sen- 
sations felt  at  the  vulva,  the  perineum,  the  rectum,  and  the  coccyx, 
the  frequent  inclination  to  urinate,  the  fulness  at  the  hypogastric 
region,  the  pain  in  the  "  small  of  the  back,"  down  the  limbs,  in  the 
hips,  around  to  the  iliac  and  hypogastric  regions,  are  all  of  the 
same  type.  At  the  period,  these  symptoms  of  pain  and  distress 
become  much  aggravated,  and  often  intense ;  the  irritation  ex- 
tends from  the  nerves  to  the  muscles,  hence  the  spasmodic  pains, 
violent  cramps  of  the  uterus,  of  the  vagina,  and  of  the  sphincters. 
These  spasmodic  affections  are  often  of  the  most  severe  charac- 
ter, usually  occurring  in  paroxysms,  for  hours,  or  even  for  days ; 
and  sometimes,  although  then  more  moderately,  during  the  whole 
period.  They  simulate  the  pains  and  agony  of  labor ;  and  they 
are  equally,  if  not  more  agonizing,  for  they  are  more  protracted, 
and  the  intervals  are  less  decided;  sometimes,  indeed,  the  pain  is 
almost  continuous.  Usually,  after  the  first  twelve  or  twenty-four 
hours,  when  the  secretion  of  the  menses  is  fully  established,  the 
pain  and  spasms  moderate,  or  cease.  Frequently,  two  or  three 
days  elapse  before  the  poor  woman  returns  to  her  usual  state ;  and 
often  the  sufi'ering  is  so  severe  and  so  prolonged,  that  the  whole 
interval  does  not  afford  her  sufl&cient  time  for  recruiting  her  pros- 
trate energies.  The  succeeding  catamenial  period  brings  renewed 
neuralgia  and  spasms ;  and  so  on,  even  for  successive  years,  de- 
priving the  sufferer  of  all  social  and  intellectual  happiness.  .  Her 


VAGINAL    EXAMINATIONS.  Ill 

life  is  a  life  of  suffering,  and  her  joys,  if  any,  must  come  from 
things  moral  and  things  spiritual.  In  very  many  cases,  however, 
there  is  not  much  pain  during  the  interval ;  the  patient  is  ill  for 
her  day,  or  days,  and  then  feels  comfortable  and  happy  for  an- 
other twenty-five  or  seven  days.  The  whole  character  of  the 
symptoms  now  detailed  (the  suddenness  of  their  occurrence,  their 
severity,  their  spasmodic  and  paroxysmal  character,  their  perio- 
dicity, their  continued  recurrence  month  after  month,  even  year 
after  year,  in  patients  often  otherwise  healthy,  and  in  no  cases 
dangerous  or  fatal)  indicates  nervous,  not  organic,  irritation. 

This  view  is  confirmed  by  the  general  oi*  sympathetic  symp- 
toms, as  also  by  vaginal  examinations,  by  the  touchy  or  by  the 
speculum. 

In  severe  cases  of  irritable  uterus,  all  vaginal  examinations 
become  excessively  trying,  especially  when  made  by  the  speculum. 
In  a  few  instances,  local  spasms  and  general  convulsions  have  been 
excited.  The  introduction  of  the  finger  causes  pain,  even  when 
unguents  have  been  freely  employed,  and  the  operation  most  ten- 
derly performed.  The  suffering  is  greatest  when  pressure  is  made 
at  the  anterior  margin  of  the  vagina,  especially  near  the  orifice  of 
the  urethra.  If  the  finger  be  pressed  upon  the  posterior  edge  of 
the  vagina,  the  sensibility  is  less  disturbed,  and  the  entrance  of 
the  finger  more  easily  accomplished.  The  sensitiveness,  along 
the  course  of  the  vagina,  varies  exceedingly.  In  many  cases, 
the  whole  passage  becomes  excessively  irritable,  so  that  the  least 
motion  of  the  finger  gives  great  pain,  and  excites  spasmodic  con- 
tractions, not  only  of  the  sphincters  of  the  vagina  and  rectum,  but 
of  the  whole  length  of  the  vagina;  so  that  a  finger  or  pessary  is 
firmly  embraced,  rendering  the  removal  of  the  one  or  the  other 
exceedingly  painful.  Generally,  however,  a  vaginal  examination 
does  not  give  rise  to  much  irritation;  the  finger  can  be  slowly 
moved  from  side  to  side,  without  much,  if  any,  uneasiness  to  the 
patient.  If  carried  anteriorly,  the  cystic  irritation  is  often  dis- 
tressing, and  a  disposition  to  urinate  excited.  Pressure  against 
the  rectum  is  also  uncomfortable  to  the  patient. 

As  soon,  however,  as  the  least  pressure  is  made  against  the 
uterus,  a  severe,  darting  pain  is  felt ;  few  patients  bear  it  without 
an  exclamation,  and  a  shrinking  from  the  contact.  It  has  been 
debated  as  to  what  part  of  the  uterus  is  most  sensitive.  Doubtless 
this  varies  exceedingly;  although  the  os  and  the  cervix  may  be 


112  LOCAL    SYMPTOMS    OF    IRRITABLE    UTERUS. 

considered  as  usually  the  most  excitable,  yet  few,  who  have  made 
extensive  and  careful  examinations,  but  will  allow  that  probably 
every  part  of  the  uterus  may  be  involved.  Hence,  when  pressure 
with  the  finger  is  made  on  the  anterior  surface  of  the  neck  and 
body  of  the  uterus,  pain  and  uneasiness  are  excited  not  only  in  the 
bladder,  but  also  in  the  uterus.  So,  also,  the  sides  of  this  organ 
are  often  very  irritable ;  and,  especially  in  cases  of  retroverted 
uterus,  we  frequently  discover  how  exquisitely  sensitive  is  the 
whole  posterior  portion.  Patients  will  not  tolerate,  without  great 
complaint,  any  pressure  by  the  finger,  or  by  pessaries,  against 
this  surface,  in  cases  of  posterior  displacement  of  the  fundus.  If 
an  examination  "per  rectum  be  made  in  such  cases,  the  agony 
becomes  still  more  intense.  The  finger,  pressing  on  the  anterior 
surface  of  the  rectum,  and  thus  against  the  posterior  surface  of  the 
uterus,  as  it  rests  on  the  bowel,  excites  a  neuralgic  irritation  of 
such  severity  that  few  patients  can  endure  it  for  more  than  an 
instant.  Direct  pressure  can  hardly  be  made  on  the  fundus  of 
the  uterus,  protected  as  it  is,  anteriorly,  by  the  tent-like  expan- 
sion of  the  abdominal  muscles,  and  by  the  mass  of  small  intes- 
tines. But  if  there  be  any  enlargement  of  the  uterus,  or  if  by  any 
other  circumstance  the  organ  is  brought  near  to  the  parietes  of 
the  abdomen,  pain  can  be  easily  excited  in  the  fundus,  by  direct 
pressure. 

Every  experiment,  therefore,  made  in  these  digital  examinations 
proves  the  sensitiveness  of  the  whole  organ,  and  that  the  posterior 
portions  and  the  extremity  of  the  neck  and  the  os  tincge  are  the 
most  susceptible  of  pain.  The  investigation  per  rectum  evinces 
generally  a  morbid  tenderness  of  this  tube,  at  its  external 
orifice,  and  throughout  its  course,  as  far  as  the  finger  can  extend, 
especially  anteriorly,  where  it  is  in  contact  with  the  uterus.  Ex- 
aminations by  the  "  touch"  not  only  detect  the  great  sensibility 
of  the  tissues,  but  also,  in  a  very  large  majority  of  cases,  some  of 
the  various  forms  or  degrees  of  uterine  displacement  coexisting, 
whether  as  cause  or  efl'ect,  or  a  mere  accidental  coincidence  will 
be  hereafter  discussed.  Few  who  are  practically,  as  well  as  theo- 
retically, acquainted  with  displacements  of  the  uterus,  but  will 
acknowledge  the  usual  coincidence  of  an  irritable  and  displaced 
uterus. 

These  are  the  positive  facts  gained  b}'"  vaginal  examination,  but 
the  negative  information  is  of  the  greatest  value.     In  all  the  uncom- 


SIMPLE    CONGESTION.  113 

plicated,  althougli  severe  cases  of  irritable  uterus,  where  it  has 
lasted  even  for  years,  there  cannot  be  discovered,  by  this  exami- 
nation, any  enlargement  of  the  uterus,  or  its  cervix.  No  indura- 
tion, no  irregularities  of  form,  no  turgescence  of  the  cervix,  no 
patulous  condition  of  the  os  uteri,  no  swellings,  even  of  the  orifice 
of  the  urethra,  of  the  vulva,  vagina,  or  rectum,  no  morbid  secre- 
tions, and,  of  course,  no  purulent  discharges  have  resulted.  In 
fact,  none  of  the  usual  consequences  of  inflammatory  action  or 
morbid  excitement  exist,  and  no  alteration  of  tissue  can  be 
detected.  The  tissues  and  organs  feel  perfectly  natural  as  to  soft- 
ness, pliability,  form,  and  size,  as  if  no  morbid  state  had  existed. 

Notwithstanding  all  that  has  been  written  and  said  upon  the 
subject,  we  must  believe  that  an  ocular  examination  confirms  these 
observations.  Although  the  use  of  the  speculum  is  itself  painful, 
and  aggravates  the  irritation  of  the  tissues,  so  that  some  tempo- 
rary organic  excitement  and  congestion  are  produced  ;  yet  in  very 
many  of  these  examinations,  no  turgescence  of  the  mucous  mem- 
brane, no  swelling  of  the  cervix  uteri,  no  patulous  condition  of 
the  OS  uteri,  no  exaltation  of  color,  no  granular  or  ulcerated  con- 
dition of  the  neck,  or  of  the  lips  of  the  organ,  are  to  be  observed. 

In  this  opinion,  namely,  that  no  organic  alteration  of  any  con- 
sequence usually  exists,  we  are  the  more  convinced,  inasmuch  as 
physicians  who  believe  congestion,  or  inflammation  and  ulcera- 
tion, to  be  the  ordinary  course  of  the  symptoms  of  irritable  uterus, 
have  dismissed  cases  as  cured  of  all  the  congestive  and  inflamma- 
tory symptoms ;  and  yet  many  of  these  patients  have  continued 
to  suffer,  as  intensely  as  ever,  from  the  symptoms  of  irritable 
uterus.  No  permanent  relief,  by  the  antiphlogistic  treatment, 
had  been  afforded.  Irritable  tissues,  we  are  confident,  may  exist 
without  turgescence  of  the  bloodvessels.  Irritability  is  a  nervous,, 
not  an  organic  affection.  Irritation  of  the  nerves  of  sensation  and 
of  motion  may  exist,  and  does  exist,  without  congestion.  But 
this  is  not  always  the  case. 


CONGESTION. 

Yery  often  congestion  does  exist,  nevertheless,  not  as  the  disease, 
"{pse  morbus,''^  but  as  a  consequence;   not  as  a  primary,,  but  a 
secondary  aff'ection.     It  is  one  of  the  sequelae  of  nervous  irrita- 
8 


114  LOCAL    SYMPTOMS    OF    IRRITABLE    UTERUS. 

tion.  Congestion,  as  a  sequence  of  irritation  of  the  cerebro-spinal 
system,  must  be  distinguished  from  the  congestion  due  to  irrita- 
tion of  the  organic  system,  which  causes  inflammation,  suppura- 
tion, ulceration,  disorganization,  etc. 

In  the  first  chapter,  the  distinction,  very  essential  as  it  is,  has 
been  stated,  between  these  apparently  similar,  but  yet  very  dis- 
similar states  of  the  vascular  system,  of  a  tissue  or  organ.  It  will 
now  be  merely  requisite  to  allude  to  the  following  facts.  Simple 
congestion,  as  connected  with  the  nervous  irritability,  has  its 
physiological  type  in  every  tissue  and  organ  of  the  body,  and 
especially  in  what  are  termed  erectile  tissues.  Also  in  morbid  ex- 
citements (in  nervous  irritations,  in  other  words),  we  may  have 
the  same  congestion.  In  all  such  cases,  engorgement  may  exist 
without  any  organic  irritation,  and  its  consequent  inflammation. 
If,  however,  the  engorgement  be  very  great  or  long  persistent  in 
a  part,  then  the  organic  actions  sometimes  become  excited  (not 
irritated),  normally  (not  abnormally).  This  is  manifested  first, 
and  far  most  frequently,  by  an  increase  of  the  natural  secretions  ; 
second,  in  many  cases  of  severe,  and  especially  of  sudden  conges- 
tions, by  effusions  of  blood ;  third,  when  such  secretions  or  effu- 
sions do  not  occur,  or  when  the  relief  by  them  is  partial,  if  the 
congestion  continues,  the  tissue  or  organ  is  more  fully  nourished  ; 
it  becomes  developed,  enlarged,  and  "  hypertrophied." 

All  these  changes  are  observable  in  many  cases  of  irritable 
uterus,  and  should  be  carefully  distinguished  (which  has  seldom 
been  done)  from  organic  irritations  and  their  consequences. 

In  tracing,  therefore,  the  progress  of  the  local  symptoms  of 
irritable  uterus,  the  decided  evidences  of  congestion  of  the  vas- 
cular system  (of  the  kind  of  congestion  resulting  from  nervous 
irritation,  as  distinct  from  organic)  will  be  noticed.  They  are 
manifested  not  so  much  by  the  sense  of  fulness,  swelling,  pres- 
sure, weight,  and  bearing  down,  etc,  all  of  which  may  be  decep- 
tive, as  by  the  results  of  vaginal  examination,  and  by  the  sequelae 
of  engorgement  to  which  allusion  has  been  made.  Often,  in. 
vaginal  examinations  by  the  touch,  it  is  evident  that  the  neck  of 
the  uterus,  although  not  indurated,  is  swollen,  as  at  the  beginning 
of  pregnancy ;  the  lips  of  the  os  are  divergent,  so  as  to  evince  a 
tumefaction  of  the  reflected  membrane  of  the  vagina,  as  it  becomes 
uterine.  The  os  uteri  is  thus  apparently,  perhaps  sometimes 
actually,  more  patulous  than   normal.     In  other  cases  there  is 


HYPERTROPHY.  115 

evidently  a  fulness  or  turgescence  of  the  whole  organ,  not,  how- 
ever, so  easily  detected  as  that  of  the  cervix.  This  enlargement 
varies  very  much,  even  in  the  same  patient ;  being,  of  course, 
greater  immediately  during  the  catamenia,  after  a  long  walk,  after 
coition,  or,  indeed,  any  physical  or  moral  excitation.  Sometimes, 
therefore,  when  the  patient  is  long  at  rest  or  free  from  excitements, 
this  swollen  condition  can  hardly  be  recognized.  Not  unfrequently 
similar  tumefactions  may  be  perceived  at  the  orifice  of  the  urethra, 
in  its  caruncle,  in  the  arborescent  vaginal  surface  under  the 
urethra,  and  throughout  this  vulvo-uterine  canal. 

By  the  speculum,  we  may  discover,  in  addition,  a  deeper  color 
of  the  tissues.  Instead  of  its  natural  pallid,  and  delicate  pink 
hue,  the  mucous  membrane  of  the  vulva,  of  the  vagina,  of  the 
cervix,  and  especially  of  the  os  tincae,  becomes  of  a  red  or  scarlet 
and  sometimes  of  a  purplish  color;  precisely  as  the  conjunctiva 
of  the  eye  is  seen  to  be  red  in  lachrymation,  or  the  skin  in  blushing 
and  nervous  flushes.  Examinations  at  different  times  exhibit  the 
fluctuating  character  of  these  congestions. 

Hypertrophy. — The  enlarged  hypertrophied  condition  can  be 
recognized  by  the  internal  assisted  by  the  external  examination 
through  the  parietes  of  the  abdomen.  The  tissue  of  the  uterus 
remains  natural,  and  does  not  become  hard,  indurated,  or  irregu- 
lar ;  the  form  of  this  viscus  is  very  little  altered,  not  even  as  much 
as  in  pregnancy.  The  womb  evidently  occupies  more  space  in 
the  pelvis,  is  nearer  to  the  pubis  as  well  as  to  the  sacrum,  while 
its  fundus  can  be  perceived  more  distinctly  than  usual  in  the 
hypogastric  region.  By  "  ballottement,"  or  balancing  the  uterus 
on  a  finger  in  the  vagina,  when  the  other  hand  is  pressed  firmly 
on  the  abdomen,  the  muscles  thereof  being  in  a  relaxed  state,  a 
tolerable  accurate  idea  may  be  formed  of  the  size  of  the  organ. 
This,  however,  is  better  effected  by  means  of  a  small  male  catheter, 
a  sound,  or  a  probe  ("  Simpson's  uterine  sound"),  passed  carefully- 
through  the  OS  uteri,  along  the  neck  and  body,  to  the  superior 
part  of  the  cavity  of  the  womb  ;  and  unless  in  cases  of  displace- 
ment, and  of  great  obesity,  of  dropsy  or  other  disease,  the  point 
of  the  instrument  may  be  felt  by  the  hand  on  the  hypogastric 
region.  With  sufiicient  precision,  the  whole  perpendicular  dia- 
meter can  thus  be  readily  measured.     In  many  cases  of  engorge- 


116  LOCAL    SYMPTOMS    OF    IRRITABLE    UTERUS. 

ment  or  hypertrophy  this  diameter  is  but  three  inches,  or  about 
six  lines  more  than  its  natural  length.  Sometimes  it  measures 
three  and  a  half,  or  four  inches;  but  seldom  more  unless  there 
be  some  other  cause  of  hypertrophy  than  simple  irritability ;  as 
when  tumors  are  developed  on  the  interior  or  exterior  of  the 
organ.  Of  course  it  is  doubtful  to  what  extent  the  womb  may 
enlarge  in  protracted  and  severe  cases,  even  of  pure  irritability. 
Personal  experience  will,  therefore,  vary  ;  but  it  is  satisfactory  to 
know  that  it  very  rarely  exceeds  that  of  the  uterus  at  the  third 
month  of  gestation ;  and  also  when  the  cause  is  removed,  the  en- 
largement will  gradually  diminish,  almost  to  the  natural  size,  with 
perfect  integrity  to  the  functions,  not  only  of  menstruation  but  of 
gestation. 

This  hypertrophic  condition  of  the  tissues  is  now  universally 
recognized  by  pathologists,  although  many  still  maintain  that  it 
is  either  the  result  of  chronic  inflammation,  or  the  first  stage  of 
the  phlogosis  which  terminates  in  hard  induration.  Hypertrophy 
is  often  found  in  the  uterus  after  parturition  or  abortions,  after 
chronic  menorrhagia,  or  where  polypi,  fibrous  or  other  tumors 
exist  within  or  without  the  uterine  cavity.  It  is  frequently  recog- 
nized in  the  heart,  and  also  in  the  mammary  gland,  as  the  result 
of  lactation  or  of  uterine  irritation. 

A  very  learned  treatise  upon  the  subject  of  hypertrophy  of 
the  uterus  has  been  published  by  M.  Klob  and  translated  by  Drs. 
Kammerer  and  Dawson,  of  New  York,  1868.  By  M.  Klob,  the 
views  we  have  maintained  are  fully  confirmed.  He  proves  that 
the  enlargement  is  regular,  that  both  muscular  and  areolar  tissues 
may  be  developed,  but  the  "  proliferation"  usually  involves  the 
connecting  membrane ;  that  the  state  of  the  organ  is  altogether 
different  from  that  of  induration,  and  that  it  is  the  result  of  hyper- 
seraia,  but  nevertheless  entirely  distinct  from  chronic  inflamma- 
tion, and  should  not,  therefore,  be  confounded  with  "induration" 
of  the  uterus. 

It  is  to  be  observed  that  hypertrophy  may  occasionally  be  par-- 
tial ;  the  cervix  of  the  uterus  is  often  alone  interested :  so,  also, 
those  parts  of  the  body  of  the  uterus  where  tumors  or  any  other 
source  of  irritation  exist.  M.  Klob,  therefore,  speaks  of  hyper- 
trophy as  a  "  formative  irritation"  as  distinct  from  inflammation, 
which  is  a  destructive  irritation. 


MENORRHAGIA    AND    H^MORRHAGIA.  117 

Menorrhagia  and  H^morrhagia. — Congestions,  as  connected 
with  irritability  of  the  uterus,  may  be  partly  or  entirely  relieved 
by  secretions  or  by  actual  bemorrliage.  As  the  natural  engorge- 
ment of  a  catamenial  period  is  relieved  by  the  flow  of  the  menses, 
so  the  unnatural  or  excessive  congestion  at  such  times,  may  be 
moderated  or  relieved  by  inordinate  menstrual  evacuation,  in  pro- 
fessional language  by  menorrhagia. 

This,  therefore,  ought  to  be  regarded  as  a  very  common  and  a 
very  important  symptom  of  irritability  of  the  uterus;  for  by  the 
frequent  recurrence  of  the  discharge,  its  quantity,  and  its  long 
continuance,  much  serious  injury  is  often  inflicted  on  the  organic 
as  well  as  the  nervous  system.  The  patient  becomes  very  feeble, 
anemic,  dyspeptic,  and  even  dropsical ;  while  the  cerebro-spinal 
system  becomes  so  sensitive  and  irritable  that  the  mind  and  body 
are  exhausted.  Eoutine  practitioners  and  superficial  pathologists 
are  continually  regarding  all  this  nervousness  as  depending  on 
debility,  or  anaemia,  on  exhaustion  of  nerve  power :  and  the 
whole  arsenal  of  tonics  and  astringents,  of  condiments  and  stimuli,^ 
is  exhausted,  and  resort  had  to  "  change  of  air,"  to  travel  by  land 
and  by  water,  to  exercise  by  gestation,  by  walking  or  on  horse- 
back, not  only  in  vain,  but  often,  indeed,  to  positive  and  perma- 
nent mischief.  The  simple  truth  is  not  perceived,  not  even 
imagined :  that  menorrhagia  presupposes  congestion,  and  conges- 
tion irritation ;  the  irritation  an  irritant  acting  on  the  irritability 
of  the  tissue,  and  disturbing  the  normal  condition  of  the  circula- 
tion in  a  part.  Here,  as  always,  irritation  precedes  congestion, 
then  follows  an  increased  discharge  with  all  its  serious  conse- 
quences. The  irritant,  the  cause,  must  be  detected  and  removed 
in  order  that  radical  benefit  may  be  experienced.  The  local  irri- 
tation, and  not  the  condition  of  the  general  system,  is  the  cause  of 
the  congestion. 

The  degree  of  local  irritation  and  consequent  congestion  is  fre- 
quently so  great,  that  the  uterine  discharge  loses  its  proper  secre- 
tory character.  It  is  no  longer  pure  menses,  it  becomes  more  or 
less  hemorrhagic.  Fibrin,  which  in  the  menstrual  discharge  can  be 
found  only  in  small  quantities,  and  often  cannot  be  detected,  is 
now  abundant,  and  coagula  may  be  observed.  Such  large  quan- 
tities of  pure  blood  occasionally  escape,  as  not  only  to  weaken  and 
exhaust,  but  also  induce  a  wretched  ansemic  and  cachectic  state, 
which  may  terminate  in  dropsical  effusions  and  even  death.     The 


118  LOCAL    SYMPTOMS    OF    IRRITABLE    UTERUS. 

patient  dies,  it  is  said,  of  debility,  of  exliaustion.  This  is  indeed 
true ;  but  the  cai6se,  unfortunately,  of  the  effusions  and  the  subse- 
quent exhaustion,  had  not  been  investigated;  or,  rather,  the  efi'ect 
was  mistaken  for  the  cause ;  debility,  not  irritation,  being  regarded 
as  the  source  of  the  evil.  « 

Connected  with  these  indications  of  organic  debility  are  those 
of  nervous  exhaustion.  The  rule  seems  to  be  almost  universally 
true,  that  nervous  irritability  increases  as  the  patient's  organic 
life  diminishes ;  or,  as  it  may  be  expressed,  irritability  is  inversely 
as  the  strength.  Hence,  in  menorrhagia  from  irritable  uterus,  the 
whole  system  becomes  morbidly  sensitive ;  this  is  manifested  by 
a  horrible  train  of  physical,  mental,  and  moral  disturbances,  which 
render  existence  intolerable.  Should  the  cause  be  fortunately 
detected  and  removed,  the  reaction  and  subsequent  recovery  are 
often  rapid  and  wonderful, 

Leucorrhcea. — Similar  observations  are  equally  applicable  to 
another  uterine  discharge,  familiarly  known  by  the  word  "  whites;''^ 
or  professionally,  we  cannot  say  more  scientifically,  by  the  words 
^'•fluor  albus,^^  "  leucorrhoea,''^  according  as  the  Latin  or  Greek 
nomenclature  be  preferred.  By  these  words,  all  discharges  are 
included  which  flow  from  the  vagina,  whatever  may  be  their 
character,  their  sources,  or  their  causes ;  provided  they  are  not  of 
a  red  color.  The  character  of  these  discharges  varies  exceed- 
ingly, according  to  the  pathological  condition  of  the  tissues, 
whether  congestive,  inflammatory,  syphilitic,  or  cancerous.  They 
are  very  universally  regarded  by  patients,  and  too  often  even  by 
the  profession,  as  the  consequence  of  general  or  local  debilit3^ 
To  designate  this  complaint,  the  woman  says  she  has  a  "  weak- 
ness," and  desires  something  to  strengthen  her. 

More  correct  views  have  been  entertained  of  late,  and  local 
disease  has  been  detected  as  giving  origin  to  the  discharge.  It  is 
situated,  sometimes,  at  the  os  vaginge,  in  the  course  of  the  vagina, 
at  the  OS  or  cervix  uteri,  or  in  the  cavity  of  the  uterus  itself. 
Hence,  the  distinction  into  vaginal  and  uterine  leucorrhcea  is  of  great 
importance;  each  of  which  maybe  subdivided,  perhaps  advan- 
tageously, according  to  the  special  seat  of  the  disease.  Leucor- 
rhcea, both  uterine  and  vaginal,  should  be  divided  into  congestive 
or  functional  and  inflammatory. 

Leucorrhcea  so  frequently  resembles  the  products  of  inflamma- 
tory irritation,  and  actual  inflammation  is  so  often  detected  by 


LEUCORRHCEA.  119 

ocular  examinations,  that  the  idea  has  been  too  readily  embraced 
that  all  leucorrhoea  is  the  result  of  inflammation.  There  may  be 
vaginitis  or  endometritis  with  their  peculiar  discharges ;  but  in 
many  instances,  certainly  no  traces  of  inflammation  are  to  be 
found.  Yet  the  discharges  are  often  profuse  and  long  continued, 
and  the  patient's  general  health  is  wretched.  There  are  but  few 
practitioners,  therefore,  who  have  not  mourned  over  the  inefficacy 
of  remedies  for  leucorrhoea;  and  but  few  patients  who  have  not 
regarded  it  as  one  of  the  "  opprohria  medicorum^^  and  turned  aside 
to  every  variety  of  empirical  remedies. 

Functional  Leibcorrhoea. — Numerous  facts  indicate  that  there 
exists  a  functional  leucorrhoea,  arising  from  congestions,  some- 
times transient,  sometimes  permanent,  but  not  inflammatory. 

Thus,  as  respects  the  vagina,  the  serous  and  mucoid  discharges 
which  occur  in  gestation,  especially  towards  its  termination,  the 
abundant  secretion  prior  to  parturition,  and  the  more  moderate 
discharges  produced  by  onanism,  by  coitus,  and  those  so  frequently 
observed  in  girls,  or  women  of  sanguineous,  leuco-phlegmatic  or 
nervous  temperaments,  after  muscular  effort  or  fatiguing  exercise, 
are  all  evidences  of  this  variety  of  discharge.  They  are  originally 
physiological  in  their  character ;  but  may  become  morbid  under 
the  influences  of  repeated  or  continued  sources  of  nervous  irrita- 
tion and  congestion.  Thus,  in  displacements  of  the  uterus  and 
vagina,  such  congestions  often  exist,  causing  a  continual  fluor 
albus ;  which  is  indomitable,  until  the  cause  be  removed. 

Functional  leucorrhoea  is,  however,  far  more  commonly  the 
result  of  uterine  than  vaginal  congestion.  Its  existence  is  evinced 
by  ocular  examination  in  cases  of  procidentia  uteri ;  and  in  ordi- 
nary cases,  by  the  assistance  of  the  speculum,  the  fluid  can  be 
perceived  issuing  from  the  os  uteri. 

That  very  many  of  these  discharges  are  functional  and  not  in- 
flammatory, is  evident  from  the  fact,  that  they  are  so  generally 
connected  with  menstruation,  or  with  the  parturient  state,  espe- 
cially after  delivery.  This  is  so  much  the  case,  that  uterine 
functional  leucorrhoea  might  be  denominated  white  menstruation, 
without  conveying  any  incorrect  notion.  This  is  proved  by  vari- 
ous facts,  familiar  to  every  practitioner. 

1st.  Girls,  at  the  age  of  puberty,  have  frequently  a  menstrual 
nisus,  and  yet  no  red  discharge  for  one  or  more  periods.  The 
evacuation  is  colorless ;  sometimes  it  is  white  at  the  beginning 


120  LOCAL    SYMPTOMS    OF    IRRITABLE    UTERUS. 

and  termination,  but  red  at  tlie  height  of  the  excitement.  Some- 
times it  is  of  a  delicate  pink  color  throughout.  Such  discharges 
will  continue  for  three  or  four  days,  and  then  disappear  for  three 
or  four  weeks,  returning  with  the  usual  symptoms  of  uterine  ex- 
citement. 

2d.  In  suppression  of  the  catamenia,  the  same  kind  of  white 
discharge  often  appears,  as  its  substitute,  for  a  greater  or  smaller 
portion  of  each  month,  and  is  more  abundant  at  the  regular 
period. 

3d,  Fluor  albus  often  precedes  and  follows  the  regular  flow  of 
the  menses,  sometimes  disappearing  about  a  week  after  the  usual 
discharge  ceases.  In  some  women  it  merely  precedes  or  follows 
the  catamenia.  Occasionally  it  appears  after  unusual  fatigue  at 
the  periods,  but  not  at  other  times. 

4th.  In  many  cases  of  normal  menstruation,  where  perhaps  the 
excitement  is  inordinate,  the  menses  are  not  purely  sanguineous, 
but  are  often  intermixed  with  mucoid  secretions.  Long  strings 
of  this  combined  mucous  and  menstrual  secretion  are  discharged, 
and  have  been  described  as  "coagula"  of  blood,  from  which 
they  essentially  differ. 

5th.  Similar  discharges  are  apt  to  occur,  with  more  or  less  fre- 
quency, as  a  continuance  of  or  a  substitute  for  the  uterine  secre- 
tion, at  the  period  for  the  final  cessation  of  the  menses.  Indeed, 
they  are  often  prolonged  for  an  iudefinite  period  after  the  regular, 
full,  elaborated,  red  discharge  has  entirely  disappeared. 

6th.  It  is  often  observed  in  menorrhagic  patients,  whether 
occurring  in  early  life  or  at  the  usual  period  of  cessation  of  the 
menses,  the  red  discharge  ceasing,  the  white  follows,  and  so  alter- 
nating for  an  indefinite  period. 

These  are  all  disturbances  of  a  physiological  function ;  they 
are  of  an  abnormal  and  morbid,  but  not  inflammatory  character : 
no  evidences  whatever  of  inflammation  exist  either  at  the  time, 
or  subsequently.  The  discharges  are  usually  periodical,  and  are 
not  such  as  result  from  phlogosis.  During  life,  or  after  death, 
no  evidence  of  alteration  or  destruction  of  tissue  is  presented  in 
uncomplicated  cases,  even  after  years  have  marked  the  existence 
of  leucorrhoea. 

The  inference  seems  unavoidable ;  that,  in  uterine  leucorrhoea, 
an  irritation  is  present,  similar  to  that  which  exists  at  the  men- 
strual nisus,  and  is  followed  by  congestion  and  increased  secre- 


FUNCTIONAL    LEUCORRHCEA.  121 

tion.  Leucorrlioea  is,  therefore,  in  these  cases  of  congestion,  an 
imperfect  menstruation;  the  fluid  is  not  fully  elaborated.  It  is  a 
white  menses,  constituting  the  "Menstruatio  alba"  of  old  authors, 
and  certainly  ought  to  be  distinguished  from  all  those  diverse 
discharges  the  result  of  inflammation,  cancer,  etc.  The  source 
of  this  irritation — the  irritant — must  be  discovered  in  order  to 
relieve  the  leucorrhoea.  If,  therefore,  the  uterus  be  morbidly 
excitable,  that  is  irritable,  or  if  in  a  normal  condition  there  be 
any  unusual  excitement  of  the  organ  produced,  irritation  ensues 
followed  by  congestion,  which  is  often  relieved,  as  formerly  men- 
tioned, by  a  menorrhagic  or  hemorrhagic  discharge,  but  in  more 
moderate  cases,  by  a  fluor  albus.  By  means  of  these  discharges 
there  is  a  diminution  of  uterine  irritation  and  congestion  :  but  as 
in  menorrhagia,  the  continued  leucorrhoea  debilitates;  the  patient 
complains  more  and  more  of  feelings  of  exhaustion,  and  thus  the 
miserable  nervous  feelings,  to  which  we  have  so  frequently  alluded, 
are  enhanced. 

Of  course  in  the  same  patient,  and  still  more  frequently  in  dif- 
ferent patients,  the  appearance  and  the  wliole  character  of  these  dis- 
charges vary ;  according  to  the  states  of  the  individual's  general 
system,  of  the  diminished  or  increased  excitement  of  the  uterus, 
and  of  the  degree  of  congestion,  but  especially  according  as  the 
secretion  comes  from  the  neck  or  cavity  of  the  womb.  We  most 
frequently  find  the  discharge  tenacious,  thick,  gelatinous ;  and  of 
a  dull  whitish,  yellowish,  or  greenish  color,  evidently  the  product 
of  the  peculiar  tissues  in  the  cervix,  from  the  orifice  of  which  it 
may  be  seen  issuing.  It  is  more  seroid  or  mucoid,  and  often  of 
a  reddish  tinge,  when  it  comes  from  the  interior  of  the  body  of 
the  uterus^ 

In  very  many  instances,  the  character  of  the  discharge  may 
indicate  that  the  simple  congestion,  of  which  we  have  been  dis- 
coursing, is  complicated  with  org^anic  irritation — with  inflamma- 
tion; or,  at  times,  that  the  local  irritation  is  purely -phlogistic, 
the  result,  not  of  nervous,  but  of  organic  irritation.  Yet,  in  prac- 
tice, it  is  always  difficult  to  detect  the  beginning  of  inflammation. 
It  seems  impossible  to^trace  the  transitions  from  the  normal  to 
abnormal  stages,  or  from  one  degree  or  kind  of  morbid  affection 
to  another ;  much  has  been  done  by  means  of  microscopic  and 
chemical  tests,  but  much  remains  to  be  done.  The  practitioner 
is  anxiously  looking  for  more  efl&cient  assistance  from  his  friends 


122  LOCAL    SYMPTOMS    OF    IRRITABLE    UTERUS. 

and  collaborators,  the  microscopic  anatomist  and  tlie  organic 
chemist. 

Judging  from  the  results  of  practice,  as  already  intimated,  we 
should  infer  that  leucorrhoea  is  far  more  frequently  uterine  than 
vaginal;  and,  also,  functional  than  inflammatory.  This  is  greatly 
at  variance  with  the  published  opinions  of  pathologists ;  but  we  are 
confirmed  in  our  views  by  the  success  of  a  practice  founded  on  this 
pathological  principle.  Indeed,  we  think  that  leucorrhoea  should 
no  longer  be  regarded  as  indomitable,  an  "  op2:)rohrium  medicorum.'''' 

Infiammatory  Leucorrhoea. — This  variety  of  Fluor  Albus  is 
merely  a  symptom  of  Vaginitis,  or  Endometritis ;  and  therefore 
will  be  included  under  the  head  of  Inflammation  and  other  com- 
plications of  Irritable  Uterus. 

Dysmenorrhcea. — The  simple,  uncomplicated  form  of  dysmenor- 
rhoea  has  already  been  noticed,  in  the  beginning  of  this  chapter, 
as  a  symptom  of  irritable  uterus.  It  is  essentially  an  example 
of  nervous  irritation  of  the  uterus,  manifested  by  pain  and  spasm 
of  this  organ.  This,  however,  does  not  complete  the  pathological 
character  of  dysmenorrhoea. 

Congestive  Dysmenorrhoea. — In  every  menstrual  effort  there  is 
not  only  the  natural,  normal  excitement,  but  there  is  the  necessary 
consequent  turgescence  of  the  bloodvessels,  followed  by  a  secre- 
tion of  a  more  or  less  abundant,  sanguineous  fluid.  So  in  dif&cult 
menstruation,  the  excitement  is  extraordinary,  not  always  because 
there  is  any  more  activity  in  the  exciting  cause,  which  may  be 
perfectly  normal ;  but  because  the  susceptibility  of  the  tissues  is 
preternaturally  great — it  is  abnormal.  The  uterus  is  irritable, 
therefore  the  natural  cause  of  menstruation  is  sufficient  to  excite 
irritation,  often  to  a  very  great  degree.  But  if,  from  any  circum- 
stances— as  anxiety  of  mind,  fatigue,  disorders  of  the  stomach, 
bowels,  conditions  of  the  ovaries,  etc. — an  abnormal  uterine  irri- 
tation is  produced,  there  will  be  a  still  greater  manifestation  of 
suffering.  In  all  such  cases,  the  normal  vascular  excitement  will  be 
aggravated;  the  fulness  of  the  bloodvessels  at  the  catamenial  period 
will  become  preternatural,  inordinate.  This  is  congestion;  not 
inflammatory,  however,  but  founded  on  a  physiological  state,  which 
is  very  analogous  to  apoplectic  conditions  of  the  brain  as  com- 
pared with  its  physiological  states  in  cases  of  mental  or  moral  ex- 
citement.    When  these  catamenial  irritations  and  engorgements 


MECHANICAL    DYSMEXORRHCE  A  .  123 

are  severe,  we  speak  of  ^'■congestive  dysmenorrhoea."  By  this,  we 
mean  merely  an  aggravation  of  the  moderate  degrees  of  this  pain- 
ful disturbance ;  for  in  all  cases  there  is  more  or  less  congestion. 
The  nervous  symptoms  are,  of  course,  augmented  by  this  occur- 
rence, and  often  become  very  intense,  and,  apparently,  alarming. 
Severe  sympathetic  disturbances  of  the  brain,  spinal  marrow, 
stomach,  and  bowels  often  follow.  These  violent  agitations  are, 
however,  usually  of  short  duration,  sometimes  only  for  two  or 
three  hours.  In  most  cases  there  is  a  diminution  of  suffering  or 
excitement  within  at  least  twenty-four  hours,  even  when  more  or 
less  pain  continues  throughout  the  whole  period.  A  free  secretion 
from  the  cavity  of  the  uterus  moderates  at  once  the  engorgement 
and  the  neuralgic  spasms. 

Mechanical  Dysmenorrhoea. — Dysmenorrhoea  is  frequently  due 
to  obstructions  in  the  canal  of  the  cervix.  These  obstructions 
are  various  as  to  kind  and  degree ;  but  may  arise  chiefly  from  the 
following  sources ;  from  the  presence  of  coagula,  of  inspissated 
mucus,  of  lymph,  or  of  a  membrane  in  the  cavity  of  the  body  or 
neck  of  the  uterus;  from  turgescence  of  the  lining  membrane,  due  to 
inflammation;  from  thickening  of  the  membrane,  or  the  formation 
of  strictures;  or,  finally,  from  a  flexion  of  the  cervix  uteri,  which  is 
probably  by  far  the  most  frequent  cause  of  obstruction.  To  this 
list,  may  be  added  congenital  contraction  or  deformity  of  the 
cervix,  but  this  is  of  rare  occurrence.  All  these  give  rise  to 
spasmodic  efibrts  of  the  uterus  to  remove  the  obstruction,  and 
are  well  termed  "  mechanical  dysmenorrhoea."  These  obstructions 
will  be  noticed  under  their  appropriate  heads. 

In  cases  of  congestive  dysmenorrhoea,  when  the  excitement  is 
high,  as  was  remarked  in  some  cases  of  menorrhagia,  pure  blood 
sometimes  escapes,  and  then  coagula  are  formed,  generally  in  the 
vagina,  but  occasionally  in  the  uterine  cavity.  Particularly  when 
the  latter  has  taken  place,  the  spasmodic  symptoms  are  greatly 
enhanced;  powerful  contractions,  as  in  labor,  are  excited  and  re- 
quired for  the  expulsion  of  these  coagula  through  the  orifices 
and  canal  of  the  cervix;  a  variety  of  mechanical  dysmenorrhoea 
being  thus  superadded  to  ordinary  forms  of  congestive  dysmenor- 
rhoea. In  some  specimens  these  coagula  have  resembled  a  chest- 
nut as  to  form,  as  if  moulded  by  the  triangular  cavity  of  the  ute- 
rus. In  most  instances,  as  discharged  from  the  uterus,  they  are 
very  thin,  and  membranous-like,  sometimes  of  a  triangular  form, 


124  LOCAL    SYMPTOMS    OF    lERITABLE    UTERUS. 

and  have  been  often  mistaken  for  true  "  membranous  dysmenor- 
rhoea."  The  symptoms  of  congestion,  general  and  local,  in  some 
of  these  cases,  are  so  urgent,  that  practitioners  have  often  re- 
garded them  as  purely  inflammatory ;  and  thought  they  were  con- 
firmed in  this  opinion  by  the  appearances  of  these  membranous 
shreds,  which  they  have  regarded  as  coagulable  lymph,  the  pro- 
duct of  inflammatory  action. 

But  the  character  of  even  this  form  of  dysmenorrhoea  is  tran- 
sient; there  is  an  absence  of  proper  febrile  excitement  even  in 
the  worse  cases ;  there  is  no  appearance  of  purulent  or  other  ana- 
logous discharges;  there  is  a  perfect  integrit}?-  of  the  uterus  soon 
after  the  attack,  an  integrity  which  will  often  be  found  complete 
after  dysmenorrhoea  has  existed  even  for  some  twenty  or  thirty 
years,  there  being  no  thickening,  no  induration,  no  ulceration  of 
the  tissues.  These  observations,  together  with  the  fact  that,  dur- 
ing the  intervals,  the  general  health  and  strength  of  the  patient 
are  often  excellent,  without  even  the  loss  of  flesh  or  color,  con- 
firm the  opinion  that  dysmenorrhoea  is  essentially  a  nervous,  and 
not  an  organic  disease;  that  the  congestion,  even  when  excessive, 
is  not  inflammatory,  but  the  result  of  great  nervous,  not  organic, 
irritation. 

The  turgescence  and  soreness  of  the  mammae,  which  are  fre- 
quently observed  in  painful  menstruation,  constitute  no  argument 
in  favor  of  its  inflammatory  character.  Such  developments  are 
synchronous  with  uterine  excitements,  physiological  or  pathologi- 
cal; and  are  observable,  therefore,  not  only  at  the  age  of  puberty, 
but  at  every  monthly  period;  especially  after  marriage,  even  when 
no  conception  has  occurred ;  always  during  pregnancy ;  and  very 
generally  in  all  the  varieties  of  irritable  states  of  the  uterus,  as 
well  as  in  cases  of  positive  and  decided  inflammation.  But,  per- 
haps, this  turgescence  exists  less  frequently  in  inflammatory 
diseases ;  for  who  does  not  know  that  in  acute  metritis,  as  well  as 
in  peritonitis  of  the  puerperal  character,  the  excitement  and  con- 
gestion of  the  mammae  diminish  and  disappear,  constituting  a 
most  unfavorable  symptom. 

The  development  of  the  nervous  and  vascular  tissues  and 
actions  of  the  mammae  is  therefore  no  indication  that  dysmenor- 
rhoea is  of  an  inflammatory  type.  Indeed,  this  condition  of  the 
mammae  is  a  beautiful,  almost  visual,  exemplification  of  an  irritable 
organ,  and  a  type  of  the  uterus  in  its  states  of  nervous  irritation. 


.MECHANICAL    D YSMENOREHCE A.  125 

That  membranous  matters  Jiave  been  cast  off  from  tbe  uterus 
in  consequence  of  inflammation^  there  can  be  little  doubt,  how- 
ever rare  may  have  been  such  occurrences.  The  membrane  of 
the  uterus,  like  other  mucous  tissues,  when  inflamed,  will  discharge 
abundantly  not  merely  seroid  and  mucoid  matters,  but  also  pus ; 
and  when  the  inflammation  is  severe,  of  course  lymph  in  shreds 
or  membranes.  The  inflammation  usually  terminates  by  the  flow 
of  the  menses,  or  of  leucorrhoeal  and  purulent  matters ;  so  that 
lymph  is  very  rarely  detected,  and  never  unless  there  be  severe 
inflammation. 

Still,  there  are  very  many  difficulties,  in  attempting  to  diag- 
nosticate the  original  location  or  the  character  of  the  adventitious 
membrane.     A  few  cases  will  illustrate  this  point. 

Cases. — A  medical  friend  very  lately  presented  the  author  with 
a  beautiful  specimen,  as  he  deemed  it,  of  false  membrane  from  the 
cavity  of  the  uterus  of  a  virgin  female,  suffering  from  nervous  irri- 
tation of  the  genitals.  The  specimen,  as  supported  in  water,  had  a 
bluish  pellucid  appearance,  like  the  amnion  of  the  foetus.  It  was 
a  sac  somewhat  conical,  about  two  inches  long  and  one  and  a  half 
in  breadth.  Once  before  a  similar  specimen,  he  said,  had  passed 
from  the  same  girl,  and  on  several  occasions,  shreds  of  a  like 
character  had  been  discharged  per  vaginam.  Our  friend,  after 
a  few  days,  brought  another  specimen  from  the  same  patient, 
which  was  of  cylindrical  form.  He  insisted  that  these  membranes 
must  have  come  from  the  uterus,  although  they  did  not  appear  at 
the  catameni&l  period.  Even  when  it  was  represented  to  him,  that 
some  of  the  specimens  were  altogether  too  large  to  have  occupied 
a  uterus  of  the  normal  size,  his  opinion  was  not  changed.  The 
specimens  were  then  submitted  to  the  examination  of  Dr.  Joseph 
Leidy,  who  stated  that  the  microscope  exhibited  the  membrane  to 
consist  of  epithelial  scales,  belonging  to  the  mucous  membrane  of 
the  vagina,  and  not  of  the  uterus.  The  attending  physician  not 
only  yielded  to  this  corroborating  testimony,  but  confirmed  it, 
by  discovering  that  these  membranes  never  were  discharged 
except  after  the  injection  of  a  solution  of  the  nitrate  of  silver  into 
the  vagina  ;  which  fact  explained  the  whole  mystery.  We  have 
subsequently  attended  this  young  lady,  who  has  had  no  return  of 
similar  discharges  since  the  wash  of  nitrate  of  silver  was  omitted. 

Several  years  ago,  we  were  presented  with  a  specimen  of  supposed 
adventitious  membrane  from  the  cavity  of  the  uterus,  by  Dr.  Ken- 


126  LOCAL    SYMPTOMS    OF    IRRITABLE    UTERUS. 

necly,  a  practitioner  in  Buenos  Ayres,  S.  A.  It  was  of  a  triangular 
shape,  measuring  about  three  and  a  half  inches  from  one  angle  to 
another;  and  consisted  of  a  thick,  dense,  opaque  membrane,  rough 
upon  the  outer  surface  and  rather  smooth  on  the  inner,  forming  a 
portion  of  a  sac.  It  resembles  very  closely  a  deciduous  membrane 
from  pregnancy,  as  it  now  appears,  preserved  in  our  museum  in 
alcohol.  Dr.  K.  states  that  it  was  thrown  off  from  the  vagina  by 
a  woman  who  was  exceedingly  ill,  with  violent  chill,  fever,  great 
pain,  and  other  symptoms  of  inflammation;  and  he  regarded  it, 
therefore,  as  the  result  of  severe  endometritis.  Two  important 
facts  would,  however,  seem  opposed  to  this  idea:  the  one  just 
mentioned,  of  its  apparent  identity,  not  with  lymphatic  effusions 
from  inflamed  surfaces,  but  with  the  membrana  decidua;  the 
other,  its  great  size  and  development  showing  it  could  not  have 
occupied  the  cavity  of  a  uterus,  unless  hypertrophied  from  preg- 
nancy or  some  other  cause.  A  more  plausible  supposition  is,  that 
it  was  a  caducous  membrane,  the  product  of  conception,  and  that 
delivery  had  been  excited  by  the  occurrence  of  metritis. 

Membranous  Dysmenorrhcea. — In  this  connection  we  will  mention 
the  following  case  of  what  has  been  called  membranous  dysme- 
norrhcea. 

A  lady,  about  thirty-three  years  of  age,  very  healthy  in  her 
appearance,  rather  fleshy,  and  of  good  color,  was  married  twelve 
years  ago.  On  her  first  pregnancy,  she  was  very  ill  from  nausea, 
vomiting,  pain,  and  was  confined  to  her  bed  for  five  months,  an 
abortion  taking  place  within  the  fourth  month  of  gestation.  Two 
subsequent  abortions,  at  early  periods  of  pregnancy,  ensued  at 
intervals  of  eight  to  twelve  months.  Ten  years  ago,  after  many 
threatenings  of  miscarriage,  she  gave  birth  to  a  living  child.  In 
1856  she  again  considered  herself  pregnant,  had  a  supposed  abor- 
tion within  the  second  month,  but  merely  a  membrane  was  ob- 
served among  the  discharges.  In  February,  1859,  a  similar 
accident  occurred  after  six  weeks  of  supposed  pregnancy.  In 
July  following,  a  decided  abortion  ensued.  In  October,  of  the 
same  year,  there  was  another  membranous  discharge  of  small 
size,  occurring  after  a  suspension  of  the  menses,  and  regarded  at 
the  time  as  another  miscarriage.  In  February,  1860,  she  again 
intermitted  her  menses,  and  considered  herself  as  pregnant.  On 
the  twentieth  of  February,  when  about  six  weeks,  according  to 
her   calculation,   had    elapsed,    irregular    pains   and   discharges 


MEMBRANOUS    D  YSMEXORRHOE  A  .  127 

supervened ;  she  became  very  sick,  and  was  confined  to  lier  bed ; 
no  decided  hemorrhage  or  menses  appeared  until  the  eleventh  of 
March,  when,  with  much  pain  and  hemorrhage,  a  large  mem- 
brane was  thrown  off,  measuring,  she  reported,  at  least  three 
inches  in  length,  and  quite  firm  in  its  character.  When  the 
membrane  was  examined  (not,  however,  microscopically)  by  her 
physician,  it  was  considered  by  him  as  the  product  of  dysmenor- 
rhoea.  Bloody  and  mucoid  discharges  continued  uninterruptedly, 
until  the  beginning  of  April,  full  six  weeks  from  their  first 
accession  on  the  twentieth  of  February.  Early  in  April  she 
came  under  our  supervision ;  she  had  all  the  external  appearance 
of  a  very  healthy  woman,  but  complained  of  being  very  nervous 
and  easily  fatigued,  with  uneasy  sensations  in  the  pelvic  region, 
a  frequent  desire  to  urinate,  a  sense  of  pressure  and  weight  with 
pain  in  the  back,  and  frequent  nervous  headaches.  The  uterus, 
upon  examination,  was  found  of  a  normal  size,  sensitive,  and 
slightly  retroverted.  This  displacement  was  relieved  by  a  pes- 
sary, and  a  suitable  general  treatment  resorted  to.  She  then 
menstruated  twice  at  regular  intervals,  without  peculiar  suffering ; 
the  discharge  was  natural  and  continued  its  usual  period  of  five 
days.  The  succeeding,  or  third  period,  in  June,  was  regular  as 
to  the  time  of  occurrence,  duration,  and  the  character  of  the 
menses.  The  pain  was  but  trifling,  yet  there  was  a  discharge  of 
a  membrane,  of  a  delicate,  almost  pellucid  character,  and  very 
nearly  of  the  form  of  the  triangular  cavity  of  the  uterus ;  it  was 
sacculated,  and  rough  on  the  exterior  surface,  but  smooth  inter- 
nally. This  beautiful  specimen  was  also  submitted  to  Dr.  Leidy, 
who  politely  sent  us  the  following  account. 

"  The  preparation  submitted  to  my  examination  consists  of  the 
desquamated  epithelium  of  the  uterus  entire.  It  has  the  form  of 
the  front  and  posterior  surfaces  of  the  cavity  of  the  body  of  the 
uterus.  The  smooth  surfaces  of  the  specimen  are  punctated,  like 
those  of  the  uterine  cavity  ordinarily.  The  flocculi  of  the  other 
surfaces  consist  of  the  cast  oft'  epithelia  of  the  uterine  tubular 
glands.     It  represents  the  first  stage  of  a  decidua." 

The  next  menstrual  period,  in  July,  occurred  without  pain  or 
the  discharge  of  any  membranous  matter ;  but  in  August  there 
was,  however,  some  pain,  and  some  portions  of  membranous 
matter  were  again  seen. 

From  these  facts,  it  may  be  inferred,  that   the  diagnosis  of 


128  LOCAL    SYMPTOMS    OF    IRRITABLE    UTERUS. 

membranous  dysmenorrhcea  is  ordinarily  very  uncertain ;  at  least, 
tliat  great  care  is  demanded  to  ascertain  whether  the  discharge 
be  anything  more  than  mere  portions  or  flakes  of  coagulated 
blood,  whether  it  be  a  proper  lymphatic  effusion,  the  result  of 
inflammation,  whether  it  be  one  of  the  membranes  of  the  ovum 
thrown  off  in  early  pregnancy,  or  whether  it  be  a  tissue,  con- 
nected with  undue  menstrual  excitement. 

The  history  of  the  last  case  mentioned  being  received  from  the 
patient,  is  therefore  deficient  in  some  of  its  details ;  but,  never- 
theless, exhibits  the  practical  difficulty  in  diagnosis.  Three  of 
these  discharges  were  cases  of  reputed  abortion;  the  fourth,  which 
occurred  in  February,  was  at  first  considered  also  as  a  case  of 
pregnancy  and  abortion,  until  the  physician  made  a  superficial 
examination  of  the  membrane,  and  pronounced  from  its  appear- 
ance that  it  was  the  result  of  dysmenorrhcea.  The  probability, 
however,  is,  that  it  was  an  abortion :  because  the  lady  had  gone 
two  weeks  beyond  her  regular  monthly  period ;  the  discharge, 
for  the  first  two  weeks,  was  abnormal  and  irregular,  watery  and 
bloody,  appearing  in  small  quantities  with  occasional  pains,  and 
at  times  disappearing  altogether ;  then  severe  pain  and  hemor- 
rhage occurred,  and  a  casting  off  of  a  membrane  nearly  three 
inches  in  length,  much  larger  than  an  unimpregnated  uterine 
cavity  could  contain ;  this  was  followed  by  sero-mucoid  and  san- 
guineous discharges  for  three  weeks — very  analogous  certainly 
to  the  lochise  after  abortions ;  and  finally,  the  occurrence  for  two 
successive  periods  of  the  menses  in  a  perfectly  normal  manner. 
It  is  doubtful,  therefore,  in  this  case,  whether  there  was  any  true 
menstrual  membrane  prior  to  the  month  of  June,  and  even  then 
it  was  thrown  off  without  pain ;  at  that  time  no  suspicions  of 
pregnancy  existed,  and  the  discharges  were  otherwise  perfectly 
regular. 

The  nature  of  this  membrane  we  leave  to  the  investigations  of 
the  microscopist :  whether  it  be,  as  Dr.  Simpson  supposes,  the 
proper  mucous  tissue  of  the  uterus  thrown  off;  or  a  mere  exfo-- 
liation  or  desquamation  of  epithelial  scales,  so  abundantly  formed 
as  to  present  a  membranous  character;  and  whether  the  organized 
membrane  of  the  uterus  in  pregnancy,  the  decidua,  is  of  the  same 
or  similar  character.  We  may,  however,  safely  conclude  that 
neither  the  deciduous  membrane  of  pregnancy  nor  the  membrane 
sometimes  seen  in  dysmenorrhcea  is  the  result  of  inflammatory 


MEMBRANOUS  D  YSMENO  RRH(E  A  .  129 

action ;  they  differ  from  lymph  in  all  their  characteristics,  and 
occur  as  physiological  rather  than  as  morbid  phenomena.  They 
seem  to  be  the  result  of  high  degrees  of  nervous  irritation  with 
congestion;  a  kind  of  hypertrophy  of  the  lining  membrane  of  the 
uterus,  so  that  epithelial  cells  and  scales  are  rapidly  generated 
and  cast  off,  occasionally  in  a  membranous  form.  The  extrusion 
of  this  membrane,  aggravating  the  pains  and  spasms  of  the  uterus, 
constitutes  another  example  of  mechanical  dysmenorrhoea, 

As  already  detailed,  irritability  is  the  proximate  or  essential 
cause  of  dysmenorrhoea.  When  this  exists,  any  normal  or  abnor- 
mal excitant  at  the  time  of  menstruation  will  produce  immediate 
suftering,  neuralgic  or  spasmodic;  when  severe,  it  is  accompanied 
with  undue  congestion,  which  may  be  followed  by  free  discharges, 
menstrual,  hemorrhagic,  or  even  by  the  formation  and  extrusion 
of  membranous  matters. 

Reference  to  the  modes  of  treatment  hereafter  indicated  will,  we 
think,  confirm  these  pathological  views  of  dysmenorrhoea ;  espe- 
cially as  women  themselves,  and  empirics,  frequently  resort  not 
only  to  narcotics,  but  to  powerful  stimuli,  even  to  pure  brand}', 
at  the  height  of  the  suffering  and  congestions  of  dysmenorrhoea, 
with  impunity  and  even  with  positive  relief. 


130  COMPLICATIONS    OF    IRRITABLE    UTERUS. 


CHAPTER   IV. 

LOCAL    SYMPTOMS    OF    IRRITABLE    UTERUS  — Continued. 
COMPLICATIONS. 

Although  the  views  above  presented  of  the  usual  forms  of 
irritable  uterus,  its  character  and  its  sequelae  (menorrhagia,  leu- 
corrhoea,  and  dysmenorrhoea),  are  correct,  yet  in  practice  many 
complications  are  often  detected. 


INFLAMMATION. 

Metritis. — Although  the  great  object  and  scope  of  this  work 
is  to  maintain  not  merely  the  existence,  but  the  great  importance, 
of  the  irritability  of  the  tissues  as  being  a  very  common  variety  of 
disease,  as  distinct  from  inflammation,  yet  there  can  be  no  doubt 
that  the  two  complaints  are  often  conjoined,  and,  moreover,  that 
a  morbid  irritability  is  often  the  sequence  of  phlogosis.  The  con- 
sequences of  nervous  irritation  are,  more  or  less,  congestion, 
effusion,  secretion,  hypertrophy,  and  the  necessary  disturbances 
arising  from  these  diseased  conditions.  These  disturbances  are 
not  unfrequently  productive  of  great  distress,  usually  accompanied 
with  much  pain,  but  also  with  debility,  antemia,  and  exhaustion. 
Patients  thus  suffering  may  be  confined  to  their  beds  for  days., 
months,  and  years,  and  yet  eventually  recover,  without  any  or- 
ganic change  in  their  tissues,  or  subsequent  impairment  of  their 
functions.  Yery  often,  indeed,  there  is  no  perceptible  enlarge- 
ment or  induration  after  years  of  suffering. 

Inflammation,  on  the  contrary,  the  result  of  organic  irritation, 
although  it  may,  under  certain  modifications,  redound  to  the 
benefit  of  the  patient,  as  in  instances  of  traumatic  inflammation, 
yet,  as  a  general  rule,  is  disorganizing,  destructive  to  the  part, 
and  eventually  to  the  general  system.  Its  consequences  are  well 
known ;  suppuration,  ulceration,  induration,  gangrene,  and  spha- 


METRITIS.  131 

celus,  while  hectic  or  pyremic  fever  exhausts  and  destroys  the 
general  powers  of  the  system. 

This  statement  indicates  the  value  of  the  pathological  distinc- 
tion between  nervous  and  organic  irritation,  and  between  a  general 
active  congestion  resulting  from  the  former  and  a  more  local  or 
concentrated  congestion,  which  necessarily  ensues  from  organic 
irritation. 

The  pathology  and  therapeutics  of  inflammation  are  well  un- 
derstood by  the  profession,  but,  most  unfortunately,  especially  as 
regards  uterine  complaints,  there  is  a  great  discrepancy  of  opinion, 
1st,  as  to  the  frequency  of  phlogosis ;  2d,  as  to  its  diagnosis ;  3d, 
as  to  its  "role"  or  importance  in  sexual  diseases;  and  4th  and 
finally,  as  to  the  necessity  of  heroic  remedies  in  the  treatment  of 
the  chronic  conditions  or  sequelae  of  inflammation.  Hence,  it 
seems  desirable  that  in  this  work,  although  treating  mainly  of 
nervous  irritability,  something  more  positive  should  be  declared 
on  the  subject  of  Metritis. 

This  word  implies  an  inflammatory  condition  of  the  uterus  in 
its  totality,  involving,  more  or  less,  not  only  the  proper  paren- 
chymatous tissue,  but  also  the  mucous  lining  and  the  peritoneal 
covering  of  the  organ.  Examples  of  this  are  not  very  uncommon 
in  acute  forms  of  inflammation,  especially  as  resulting  from  par- 
turition. In  the  chronic  forms,  the  disease  must  be  considered  as 
affecting  mainly  either  the  lining  membrane,  the  substance  of  the 
uterus,  or  the  peritoneum.  It  is  well  known  that  one  or  other  of 
these  tissues  may  be  affected  separately  without  any  serious  dis- 
turbance of  the  other  tissues.  Hence  pathologists  speak  of  endo- 
metritis, sometimes  involving  the  whole  mucous  membrane,  but 
most  frequently  affecting  only  the  lining  membrane  and  append- 
ages of  the  cervix ;  a  proper  metritis,  or  inflammation  of  the 
substance  of  the  uterus ;  and  finally,  peri-uterine  or  pelvic  peri- 
tonitis. It  is  on  these  subdivisions  of  uterine  inflammation,  when 
of  a  chronic  form,  that  discussions  have  been  instituted.  Their 
frequency  has  been  greatly  overrated  by  confounding  all  pelvic 
diseases  under  some  one  general  denomination,  not  unfrequently 
as  an  affection  of  the  uterus  or  of  the  pelvic  viscera,  or  as  a  con- 
gestion or  engorgement,  as  we  have  seen,  even  with  such  a  great 
pathologist  as  M.  Velpeau,  who  could  form  no  idea  of  engorgement 
but  as  that  of  chronic  inflammation.  Dr.  Bennet  refers  almost 
everything  to  inflammation  and  ulceration  of  the  cervix ;  and  his 


132  COMPLICATIOXS    OF    IRRITABLE    UTERUS. 

followers  have  been  exceedingly  numerous.  The  observations 
and  quotations  already  made  respecting  morbid  irritability  of  the 
tissues,  and  the  consequent  congestion  and  sometimes  hypertrophy 
of  the  organ,  if  correct,  as  we  firmly  believe,  would  remove  from 
the  list  of  inflammatory  complaints  a  large  number  of  the  diseases 
thus  named.  Our  experience  fally  confirms  this  opinion,  that 
congestion  and  its  consequences,  irrespective  of  inflammation, 
embrace  a  very  large  proportion  of  pelvic  complaints. 

Even  when  phlogosis  does  exist,  it  is  usually  confined  simply 
to  the  mucous  membrane  of  the  cervix.  Most  acknowledge  the 
•comparative  .rarity  of  inflammation  of  the  parenchyma  of  the 
organ,  notwithstanding  the  continual  reference  to  it  by  Dr.  Ben- 
net;  and  although  M.  Bernlitz  has  written  much  and  elaborately 
on  the  subject  of  "  pelvi-peritonitis,"  yet  thus  far  he  has  had  but 
few  followers,  and  the  probability  is  that  this  local  peritonitis  may 
be  regarded  as  comparatively  unfrequent,  resulting  secondarily 
from  irritations  of  the  uterus,  or  perhaps  more  generally  as  being 
entirely  independent  in  its  origin. 

Inflammation  of  the  mucous  membrane  of  the  cavity  is  gene- 
rally regarded  as  not  very  common,  being  the  consequence  and 
rather  dependent  on  inflammation  of  the  cervix,  and  therefore 
disappearing  when  that  is  relieved. 

General  Sjjmjotoms. — We  may  anticipate  some  tendency  to  in- 
flammatory action  where  any  of  the  usual  causes  of  inflamma- 
tion have  been  operative ;  when  the  patient  has  been  exposed  to 
sudden  transitions  of  temperature,  especially  at  her  catamenial 
periods ;  when  the  symptoms  occur  very  speedily  after  labor, 
whether  premature  or  at  term,  but  especially  after  difficult  and 
tedious  labor,  and  in  those  cases  where  instrumental  assistance 
has  been  demanded ;  when  there  has  been  an  employment  of  pes- 
saries of  an  improper  shape  or  of  corruptible  materials,  or  where 
such  instruments  have  pressed  too  firmly  or  too  long  on  the 
uterine  tissues ;  in  cases  of  metastatic,  cutaneous,  rheumatic,  and 
gouty  diseases ;  and  whenever  mechanical,  chemical,  or  other 
irritants  have  disturbed  the  organism  of  the  uterine  tissues.  Our 
suspicions  should  be  much  increased  if  we  discover  decided  shreds 
of  coagulable  lymph  or  an  admixture  of  purulent  matter  in  the 
vaginal  discharges,  and  especially  if  general  febrile  excitement 
should  coexist. 

These  suspicions  can  generally  be  verified  by  examinations 


CERVICAL    ENDOMETRITIS.  133 

with  the  speculum  and  by  the  touch.  It  should  be  borne  in  mind, 
however,  that  a  very  limited  portion  of  the  uterus  can  strictly  be 
seen  or  felt.  So  that  inflammation  of  the  cavity,  the  substance, 
or  of  the  exterior  of  the  uterus  cannot  be  determined  by  the 
speculum,  which  exposes  to  view  merely  the  os  uteri  externum 
and  the  extremity  of  the  cervix.  The  uterus  is  virtually  a  viscus 
in  the  peritoneal  cavity,  surrounded  by  the  intestines  and  bladder, 
and  with  merely  its  smallest  extremity  projecting  into  the  vagina. 

These  inflammations  of  the  uterus  will  be  considered  under 
the  heads  of  Endometritis  and  Metritis.  The  former  embraces  two 
sub-divisions:  one,  inflammation  of  the  mucous  membrane  of  the 
cervix,  and  the  other,  that  of  the  body;  or  cervical  or  corporeal 
endometritis :  metritis,  or  inflampiation  of  the  parenchymatous 
tissue  of  the  uterus,  is  sometimes  general,  but  not  unfrequently 
simply  cervical^  and  occasionally  corporeal. 

To  these  varieties  may  perhaps  be  added,  in  the  opinion  of 
some  authors,  inflammation  of  the  peritoneal  covering  of  the 
uterus,  and  hence  termed  "  Peri-uterine"  or  "  Pelvi-peritouitis." 

Cervical  Endometritis. — This  inflammation  of  the  mucous 
membrane  of  the  uterus  presents  precisely  the  phenomena  charac- 
teristic of  inflammation  of  mucous  tissues  in  other  parts  of  the 
body,  modified  of  course  by  any  local  peculiarities  of  structure 
and  functions.  Hence,  in  cervical  endometritis  there  is  redness, 
tumefaction,  and  increased  secretion  from  the  whole  of  the  papillary 
surface,  and  from  all  the  innumerable  ducts  and  follicles  with 
which  the  neck  is  so  abundantly  supplied :  the  mucous  and 
gelatinous  secretions,  which  are  characteristic  of  their  healthy 
state  are  gradually  altered;  they  become  thicker,  saponaceous, 
yellowish,  and  sometimes  entirely  purulent.  This  purulent 
discharge  is  very  universally  without  ulceration,  precisely  as  is 
very  often  observed  in  conjunctivitis,  otitis,  and  superficial  inflam- 
mations of  the  skin,  as  after  slight  burns,  or  from  behind  the  ears 
of  infants  during  dentition,  etc.  Occasionally,  plastic  lymph 
also  appears  as  a  consequence  of  inflammation,  similar  to  the 
false  membranes  sometimes  noticed  intrachitis,  enteritis,  colitis,  etc. 

Subsequently,  the  mucous  membrane  becomes  altered,  the  epi- 
thelium disappears,  the  papillae  are  denuded,  the  surface  is 
"abraded"    or    "raw"    without    anv  marked  turgescence.     Ere- 


134  COMPLICATIONS    OF    IRRITABLE    UTERUS. 

quently,  the  papillae  are  swollen,  becoming  red,  prominent,  some- 
times united,  presenting  a  rough  surface,  resembling  the  granula- 
tions of  a  healing  ulcer.  This  is  now  often  termed  "  granular 
inflammation."  Surgeons  have  long  been  familiar  with  a  similar 
state  of  the  mucous  membrane  of  the  eye,  which  has  been  termed 
"granular  conjunctivitis."  They  knew  well  that  this  granular 
condition,  even  when  accompanied  with  large  discharges  of  pus, 
could  exist  for  days  and  even  months  without  any  solution  of 
continuity,  without  any  ulceration  ;  and  that  the  whole  might 
disappear  without  any  permanent  thickening  of  the  tissue,  any 
induration  or  any  cicatrization ;  the  tissue  might  return  to  its 
normal  state. 

All  these  changes  in  the  appearance  and  in  the  discharges  of  the 
cervix  uteri  can  be  easily  recognized  through  the  speculum.  In 
the  earlier  stage  we  usually  perceive  redness  of  a  bright  shade 
occupying  portions  of  the  cervix,  or  very  intense  at  one  spot,  and 
gradually  diminishing  from  it  as  a  centre ;  if  this  redness  be 
observed  at  the  lips  of  the  os  tineas,  and  gradually  lessens  on  the 
vaginal  surface  of  the  neck,  we  have  reason  to  believe  it  is  of  an 
inflammatory  character,  and  that  the  inflammation  is  seated  in  the 
mucous  tissue  of  this  portion  of  the  neck.  Care  should  be  taken 
to  distinguish  this  from  any  accidental  engorgement,  due  to  the 
menstrual  or  sexual  excitement,  or  to  the  pain  or  irritation  arising 
from  the  pressure  and  distension  produced  by  the  speculum  itself. 
The  redness  varies  exceedingly,  sometimes  being  but  slightly 
exalted  above  the  natural  delicate  pink  tinge,  and  sometimes 
intensely  crimson,  as  in  severe  cases  of  phlogosis  elsewhere.  The 
neck,  as  often  seen  through  the  speculum,  in  these  cases  of  inflam- 
mation, has  been  aptly  compared  to  a  ripe  cherry. 

The  above  granular  condition  of  the  membrane  of  the  cervix 
has,  of  late  3^ears,  most  unfortunately  been  designated  as  an  "  ulcer." 
This,  with  the  inflammatory  symptoms  attendant,  has  been  lately 
regarded  as  the  chief  source  of  mischief,  and  as  originating,  in 
most  instances,  those  uterine  symptoms  which  we  have  described 
as  mainly  dependent  on  "  irritable  uterus."  This,  however,  is  not 
proper  ulceration.  There  is  an  exfoliation  of  the  epithelial  scales, 
a  development  of  the  papillae  of  the  basement  membrane  with 
more  or  less  turgescence  and  elevation  of  the  inflamed  surface ;  but 
there  is  no  "solution  of  continuity"  in  the  tissue,  no  depression, 
no  loss  of  substance,  no  generation  of  new  material — as   in   a 


CERVICAL    ENDOMETRITIS.  135 

granulating  ulcer.  And,  wlien  recoveries  ensue,  there  is  no  cica- 
trix, no  thickening,  no  contraction  of  the  tissues,  and  no  conse- 
quent alteration  in  the  form  of  the  part  affected.  At  the  os  uteri, 
the  mucous  membrane  and  the  parts  adjacent,  precisely  as  in 
analogous  states  of  the  conjunctiva  of  the  eye,  return  to  their 
original  normal  state,  and  the  tissues  are  as  perfect  as  if  they  had 
never  been  inflamed.  We  have  never  seen  an  ulcer  of  the  uterus,  a 
proper  "  solution  of  continuity"  of  the  basement  membrane,  except 
as  the  result  of  contusions,  or  wounds,  or  of  peculiar,  specific,  or 
malignant  disease.  All  this  may  be  regarded,  perhaps  justly  so, 
as  a  debate  as  to  the  meaning  of  the  word  "  ulcer."  But  "  words 
are  things  ;"  at  least,  they  ought  to  represent  things  and  facts  cor- 
rectly. The  Hunterian  definition  of  an  ulcerated  surface  (as  inti- 
mating a  solution  of  continuity,  a  destruction  of  tissue)  has  been 
so  universally  and  so  long  received  by  the  profession,  that  to 
extend  its  employment  to  a  condition  of  the  tissues  where  there 
has  been  no  destruction  of  tissue,  is  to  confuse  the  minds  of 
practititioners  as  well  as  of  students,  to  convey  incorrect  ideas  of 
the  views  of  the  writer,  erroneous  pathological  notions,  and  to 
cause  manifest  and  mischievous  errors  in  practice.  All  these 
evils,  and  much  greater,  in  our  judgment,  have  resulted  from  the 
application  of  the  word  ulcer  to  such  inflamed  surfaces  of  the 
uterus.  The  bad  influence  on  the  mind  and  imagination  of 
suffering  nervous  women  is,  by  no  means,  the  least  of  these  evil 
consequences.  Ulcers  with  them  are  associated  with  the  idea  of 
destruction,  of  an  "  eating"  process,  of  something  dangerous,  in- 
tractable, malignant.  And  there  have  not  been  wanting  those, 
in  and  out  of  the  profession,  who  have  magnified  these  dangers 
and  stimulated  the  excited  mental  sensibilities  of  the  patient  for 
their  own  selfish,  sordid  purposes.  Empiricism  and  ignorance 
have  gained  a  rich  harvest  from  this  apparently  trifling  source. 
Often,  very  often,  have  we  examined  patients  who  were  reported 
by  physicians  and  others  to  have  ulcers  where  none  could  be 
detected,  or  to  have  had  them  where  no  vestige  of  them,  no  hard- 
ening, no  cicatrization,  could  possibly  be  found. 

Cases. — A  lady  of  education  and  refinement  travelled,  at  the 
seventh  month  of  utero-gestation,  some  three  hundred  miles  to 
Philadelphia,  in  a  state  of  great  mental  excitement,  because  her 
physician  had  declared  that  she  had  an  ulcer  of  the  uterus.  None 
could  be  detected  ;  the  tissues  were  normal,  and  she  immediately 


136  COMPLICATIONS    OF    IRRITABLE    UTERUS. 

returned  home  relieved  of  her  imaginary  destructive  disease, 
her  mind  and  heart  rejoicing  with  pleasing  anticipations  for  the 
future. 

In  another  instance,  a  fine  healthy  young  lady,  the  mother  of 
several  children,  and  who  was  then  nursing  a  fat  lovely  child  of 
six  months  of  age,  presented  herself  from  a  distant  State,  com- 
plaining of  pain,  a  sensation  of  dragging,  and  weakness,  an  ina- 
bility to  walk,  etc.  She  had  been  for  some  three  years,  even 
while  pregnant,  treated  by  caustics  for  ulceration  of  the  cervix. 
By  examination  with  the  speculum,  a  slight  redness  was  observed 
at  and  near  the  os  uteri ;  that^  said  her  husband,  who  had  been 
accustomed  to  assist  her  physician  in  his  examinations,  is  the 
ulcer,  exactly  as  it  has  always  appeared.  We  found,  however,  that 
the  uterus  was  completely  retroverted  ;  by  relieving  this  displace- 
ment and  using  some  astringent  wash,  in  a  few  weeks  our  patient 
was  free  from  uncomfortable  feelings,  could  walk  at  pleasure,  and 
felt  perfectly  well,  to  the  astonishment  of  her  husband  and  friends. 

Under  similar  circumstances,  a  like  result  has  been  obtained  in 
innumerable  cases. 

We  are  much  indebted  to  Dr.  Lee,  and  especially  to  Dr.  West, 
for  demonstrating  the  infrequency  of  these  so-called  ulcerations 
of  the  uterus,  and  still  more  for  maintaining  that  the  local  a,nd 
general  symptoms  are  comparatively  little  modified  by  their  pre- 
sence or  their  absence.  It  seems  to  be  substantiated,  that  these 
epithelial  abrasions  may  exist  without  any  perceptible  aggrava- 
tion of  the  symptoms,  and,  moreover,  that  they  may  be  dissipated 
without  any  perceptible  amelioration.  Dr.  Tyler  Smith  goes  still 
further,  and  considers  all  these  abrasions  as  mere  accidents  result- 
ing from  a  prior  disease,  chiefly  leucorrhoea,  the  symptoms  of 
which  are  often  as  urgent  with  or  without  the  abrasions. 

From  these  statements  it  appears  that  inflammation  of  the  mu- 
cous membrane  of  the  cervix  is  followed  as  in  other  analogous 
tissues,  first  by  increase  of  the  mucous  and  seroid  secretions, 
rarely  by  the  formation  of  plastic  lymph,  more  frequently  by 
suppuration  and  by  epithelial  abrasions,  and  these  by  granulated 
conditions  of  the  membrane.  Occasionally  the  granules  become 
fungous  and  protrude.  Hence,  we  hear  of  fungous  or  cock's- 
comb  ulcers  of  the  os.  When  the  patient  is  exhausted  by  chronic 
disease,  or  by  some  cachectic  condition,  these  granules  occasion- 
ally disappear,  and  in  a  few  instances  a  slight  superficial  ulcera- 


CERVICO-METRITIS.  137 

tion  or  proper  loss  of  tissue  may  be  observed ;  but  deep  ulcera- 
tions of  the  cervix,  excepting  in  cases  of  sypbilis,  cancer,  or 
phagedenic  ulcerations,  are  perhaps  never  met  with. 

Ectrojnon  of  the  os  titeri,  when  great  turgescence  of  the  mucous 
membrane  of  the  os  uteri  exists,  especially  when  accompanied  with 
enlargement  of  the  papillae,  consists  in  an  eversion  of  the  lips,  so 
that  the  whole  extremity  of  the  cervix  is  soft,  apparently  open, 
and  is  said  to  be  ulcerated.  It  is,  however,  a  simple  mechanical 
result  arising  from  swelling  of  the  membranes ;  it  is  an  ectropion, 
precisely  analogous  to  a  similar  condition  of  tissue  noticed  fre- 
quently in  ophthalmia,  and  also  in  inflammations  of  the  lips  of 
the  mouth.  The  os  uteri  is  thus  said  to  be  enlarged,  but  a  dis- 
tinct orifice  of  the  usual  size  exists  within  the  proper  edges  of  the 
natural  os  uteri,  where  the  eversion  commences. 

It  is  evident,  therefore,  that  all  the  inflammations  about  the 
orifice  or  neck  of  the  uterus  are  in  perfect  analogy  with  those  of 
the  mucous  membranes  of  other  parts  of  the  body ;  there  is 
nothing  peculiar,  nothing  specific,  nothing  therefore  demanding 
extraordinary  and  dangerous  therapeutical  remedies :  the  only 
modifications  being  those  resulting  from  the  great  vascularity  of 
these  tissues  and  the  peculiar  anatomical  and  physiological  ar- 
rangements of  the  OS  and  cervix  uteri. 

Hypertrophy  of  the  cervix^  not  unfrequently,  inter  alia.,  results 
from  chronic  inflammation  of  the  mucous  membrane  when  of  a 
moderate  character.  The  constant  determination  of  blood  to  the 
inflamed  part  causes  congestion,  hypertesthesia,  and  hypernutri- 
tion  of  the  neck  of  the  uterus.  It  becomes  larger,  longer,  and 
somewhat  more  dense  as  observed  during  pregnancy. 

If,  however,  inflammation  of  the  membrane  be  more  severe 
or  more  protracted,  it  may  extend  to  the  contiguous  tissues,  and 
hence  partial  metritis,  or  inflammation  of  the  cervix  may  ensue, 
followed  by  the  effusion  of  plastic  lymph.  Hence,  with  an  in- 
creased size,  there  are  hardness,  alteration,  and  induration  of  the 
cervix. 

Cervico-Metritis. — When  inflammation  is  present,  we  find 
that  it  often  extends,  especially  in  chronic  cases,  from  the  mucous 
membrane  to  the  subjacent  tissues,  often  involving  the  whole 
substance  of  the  cervix  uteri,  but  not  usually  the  body,  of  the 
womb.     It  is  generally  a  case  of  partial  or  circumscribed  metritis. 


138  COMPLICATIONS    OF    IRRITABLE    UTERUS. 

The  cervix  is  large;  sometimes  it  is  twice  its  normal  thickness, 
or  even  more ;  not  from  simple  turgescence  or  congestion,  but 
from  actual  induration.  It  is  hard,  but  still  smooth  and  regular 
to  the  touch,  and  often  sensitive.  The  vaginal  extremity  is,  of 
course,  broad,  and  presents  a  flat  surface,  smooth,  and  bounded 
by  a  thin,  delicate  elevation,  which  can  be  recognized  as  the  natu- 
ral exterior  margin  of  the  lips  of  the  uterus ;  this  surface  being, 
however,  more  circular  than  the  natural  elliptical  form.  Hence 
we  have  another  variety  of  "  eversion"  of  the  lips  of  the  os  uteri. 

The  condition  of  the  os  uteri,  in  such  cases,  varies,  sometimes 
being  apparently  patulous,  owing  to  the  eversion  of  the  mucous 
membrane ;  but  in  reality  rather  contracted,  from  the  thickening 
and  induration  of  the  parietes  of  the  neck.  By  the  finger,  it  is 
felt  as  a  dimple  towards  the  centre,  but  sometimes  nearer  the 
anterior  or  posterior  margin,  as  one  or  other  lip  is  most  enlarged. 
The  whole  of  this  everted  surface  has  a  more  delicate  and  velvety 
feeling,  than  that  of  the  external  surface  of  the  neck.  It  seems 
to  have  been  noticed  by  some,  as  an  ulcerated  surface  of  large 
size,  "a  large  ulcer."  But  there  is  no  solution  of  continuity. 
This  everted  surface  is  often  irregular,  and,  not  unfrequently, 
small,  hard  elevations  can  be  felt  at  the  margin  of  the  lips,  near 
the  OS  uteri,  or  at  other  points ;  as  if  from  the  development  and 
induration  of  the  glands  or  glandular  follicles  of  the  tissue.  This 
delicate  surface  is  sometimes  so  congested  that  hemorrhage  arises 
from  all  these  vaginal  examinations,  and  even  when  the  patient 
moves  about,  or  has  an  evacuation  from  her  bladder  or  bowels ; 
and  occasionally  while  she  is  perfectly  at  rest.  These  symptoms, 
indeed,  may  excite  suspicion  of  a  proper  scirrhous  or  malignant 
affection,  with  which  these  simple  inflammations  ought  not  to  be 
confounded. 

Strictures  of  the  Cervix. — All  are  familiar  with  the  existence  of 
strictures  in  mucous  canals.  Such  strictures  may  exist  in  the 
canal  of  the  cervix ;  they  result  from  the  inflammation  ex- 
tending beyond  the  mucous  surface,  involving  the  basement 
membrane  and  the  subjacent  tissues.  Plastic  lymph  is  effased  in 
some  particular  portions  of  the  tube  more  than  in  others.  The 
tissue  thickens  and  contracts,  and  thus  encroaches  upon  the  canal, 
forming  a  partial  or  complete  obstruction.  Hence  results  diffi- 
cult excretion  of  the  mucous  or  menstrual  fluids,  often  giving 
rise  to  pain  and  dysmenorrhoea.     Sometimes  the  obstruction  is 


COEPOREAL-ENDOMETRITIS.  189 

complete ;  hence,  retention  of  seroid,  mucoid,  menstrual  or  puru- 
lent, or  even  gaseous  fluids  in  the  cavity  of  the  uterus,  followed 
by  enlargement,  irritation,  etc.  Hence  we  read  of  physometra, 
hydrometra,  abscess  of  the  uterus,  etc. 

The  frequency  of  these  strictures,  according  to  modern  gyne- 
cologists, is  exceedingly  great,  and  every  variety  of  surgical  ope- 
ration by  dilatation,  the  knife,  and  even  by  excision  of  portions 
of  the  cervix  has  been  recommended.  Our  own  experience 
would  declare  that  proper  strictures  of  the  cervix  are  very  rare, 
and  hence  the  dangerous  operations  proposed  are  unjustifiable, 
being  founded  on  incorrect  pathological  views.  Still,  they  do 
occasionally  exist,  and  when  complete  call  for  a  surgical  opera- 
tion. 

Corporeal  Endometritis. — Inflammation  of  the  mucoas  mem- 
brane of  the  proper  cavity  of  the  uterus  is,  according  to  most  au- 
thors, a  comparatively  rare  afiection,  although  many,  like  Dr.  Tyler 
Smith,  Scanzoni,  and  others,  think  it  a  very  common  complaint, 
being  the  usual  cause  of  leucorrhoea ;  it  is  often  designated  as  a 
catarrhal  affection  of  the  uterus.  When  moderate,  the  discharge 
is  often  reddish  or  menstrual ;  still  more  frequently,  it  is  serous, 
and  occasionally  somewhat  bloody.  The  lymph  is  said  sometimes 
to  form  upon  its  surface,  but  this  has  seldom  been  observed ; 
neither  have  ulcerations  of  this  membrane  been  noticed.  Writers 
of  the  present  day  describe  various  elevations  or  irregular  pro- 
jections analogous,  it  may  be,  to  the  granulated  or  fungous  con- 
ditions of  the  cervical  membrane,  or  similar  to  minute  polypi. 

In  the  diagnosis  of  this  complaint,  but  little  assistance  is  to  be 
derived  from  the  speculum ;  for  there  are  no  visible  signs,  except 
the  appearance  of  inflammation  of  the  os  uteri,  and  of  purulent  or 
lymphatic  discharges.  In  addition,  we  may  infer  its  existence  from 
the  general  turgescence  and  congestion  of  the  uterus,  and  from 
the  existence  of  any  febrile  symptoms  with  loss  of  appetite  and 
emaciation  conjoined.  Dr.  Bennet  states  that  a  patulous  condition 
of  the  internal  os  uteri,  recognized  by  a  probe  passing  readily, 
would  indicate  the  presence  of  inflammation  of  the  cavities.  We 
have  often  known,  even  in  young,  unmarried  girls,  as  well  as 
in  females  who  have  borne  children,  the  probe  to  pass  with  great 
facility  and  with  little  pain  when  there  was  no  suspicion  or  evi- 
dence of  inflammation.     A  'priori,  and  from  analogy  with  other 


140  COMPLICATIONS    OF    IRRITABLE    UTERUS. 

canals,  it  would  seem  that  the  greater  the  turgescence,  and  the 
more  indurated  the  tissues,  the  greater  would  be  the  contraction 
and  the  obstruction.  This  we  know  to  be  the  case  in  urethritis, 
pharyngitis,  oesophagitis,  etc.,  and  why  not  also  in  endometritis? 
Corporeal  Hypertrophy. — Endometritis  may  be  accompanied  by 
hypertrophy  of  the  whole  uterine  tissue,  the  entire  uterus  being 
enlarged,  thickened,  especially  in  its  areolar  tissue,  but  still  soft, 
without  induration,  as  it  is  in  pregnancy.  This  "  proliferation  of 
connective  tissue"  has  been  minutely  described  by  M.  Klob  and 
others. 

Corporeal  Metritis. — In  other  instances,  proper  phlogosis  of 
the  parenchyma  of  the  uterus  ensues,  with  more  or  less  induration 
from  the  formation  of  plastic  lymph.  The  organ  then  is  hard, 
indurated,  and  enlarged  very  universally  in  every  direction. 
We  know  of  no  proof  of  the  repeated  assertion  of  Dr.  Bennet 
and  others,  that  these  inflammatory  indurations  are  often  con- 
fined to  parts  of  the  uterus,  anterior  or  posterior ;  thus  to  deter- 
mine, as  he  says,  anteversion  or  retroversion  of  the  organ.  We 
deem  this  assertion  a  mere  hypothesis. 

Proper  abscess  of  the  uterus,  or  the  formation  of  matter  within 
the  walls  of  the  uterus  is  universally  acknowledged  to  be  a  very 
rare  occurrence.  Examinations  have  proved  that  such  reputed 
abscesses  have  been  located  exteriorly;  they  are,  therefore,  regu- . 
lar  pelvic  abscesses,  the  result  of  cellulitis,  peritonitis,  ovaritis, 
etc. ;  occasionally  it  may  be  in  the  proper  cavity  of  the  body  of 
the  uterus. 

Abscess  of  the  Cavity  of  the  Uterus. — As  already  hinted,  under 
the  head  of  Corporeal  Endometritis,  suppuration  sometimes 
occurs;  and  hence,  if  there  be  an  obstruction  in  the  canal  of  the 
cervix,  pus  will  accumulate  in  the  cavity  of  the  uterus.  As  this 
increases,  the  organ  will  gradually  enlarge.  We  once  saw  an 
instance  of  this  kind,  arising  from  the  obliteration  of  the  os  uteri 
internum :  so  that  at  least  one  ounce  of  pure  pus  occupied  the 
cavity  of  the  uterus — which,  of  course,  was  larger  than  usual, 
somewhat  globular,  with  increased  density  of  its  walls.  In  such 
abscesses  of  the  uterus,  the  organ  may  increase  indefinitely,  or 
the  matter  may  be  discharged,  according  to  the  report  of  many 
authors,  in  some  few  instances,  through  the  Fallopian  tubes  into 
the  cavity  of  the  peritoneum,  where  it  may  excite  inflammation. 


ENDOMETRITIS.  141 

In  other  cases  ulceration  may  follow,  and  the  abscess  may  be 
emptied  into  the  adjacent  tubes  or  cavities. 

The  symptoms  of  cJironic  endometritis,  after  all  that  has  been  writ- 
ten, need  not  be  extensively  detailed.  The  general  symptoms,  so 
called,  are  not  pathognomonic ;  there  is  no  fever,  but  the  patient 
is  weak,  languid,  nervous,  with  more  or  less  spinal  and  cerebral 
irritation,  common  in  all  pelvic  affections.  The  local  sensations 
of  fulness,  pressure,  burning,  neuralgia,  spasm,  with  irritations  of 
the  bladder  and  rectum,  are  common  in  all  affections  of  the 
uterus;  even  the  profuse  leucorrhceal  discharges  are  not  declara- 
tive of  inflammation,  for  it  has  been  shown  that  they  may  exist 
for  a  long  time,  and  even  profusely,  without  any  proper  phlo- 
gosis.  Hence  the  diagnosis  of  inflammation  must  be  made  by 
the  finger  and  the  speculum,  while  something  can  be  learned  by 
careful  analysis,  microscopical  and  chemical,  of  the  secretions 
from  the  vagina  and  cervix. 

In  the  early  stages  of  inflammation  of  the  mucous  membrane, 
not  much  is  to  be  learned  by  the  finger.  There  is  an  unusual 
sensation  of  heat  imparted;  there  is  a  moderate  tumefaction  of  all 
the  tissues,  most  perceptible  at  the  os  uteri,  where  the  tissue  feels 
tumid,  softer,  and  more  velvety,  and  the  os  apparently  dilated — 
or  rather  the  edges  of  the  lip  slightly  everted  ;  there  is,  of  course, 
some  increased  sensibility  in  the  part. 

If,  however,  the  inflammation  has  existed  for  some  time,  the 
degree  of  apparent  dilatation  of  the  os  is  greater,  the  eversion.  of 
the  lips  miore  decided,  and  there  is  more  swelling  and  enlargement 
of  the  neck,  which  is  really  hypertrophied.  This  enlargement  of 
the  neck  is  regular,  its  length  as  well  as  diameter  being  increased, 
while  the  tissue  is  soft  and  elastic  as  in  pregnancy. 

As  to  the  sensibility,  it  varies,  being  sometimes  quite  mode- 
rate even  when  there  is  much  inflammation ;  and,  on  the  con- 
trary, often  severe  when  there  is  no  inflammation.  It  is,  there- 
fore, not  pathognomonic  of  this  phlogosed  state. 

An  eversion  of  the  lips  of  the  os  uteri,  with  a  fulness  and  pre- 
ternatural softness  of  the  mucous  membrane,  and  its  greater 
prominence,  is  usually  indicative  of  vascular  engorgement,  some- 
times of  an  inflammatory  type.  Occasionally,  however,  this 
apparently  patulous  condition  of  the  os,  and  the  swelling  of  the 
tissues,  is  the  simple  result  of  continued  pressure  in  cases- of  dis- 
placements of  the  uterus. 


142  COMPLICATIONS    OF    lERITABLE    UTERUS. 

To  confirm  the  diagnosis,  the  speculum  is  all  important,  as 
through  it  can  be  observed  the  ectropion  of  the  mucous  mem- 
brane, its  turgescence,  its  redness,  its  abrasion,  its  granulations, 
and,  perhaps,  in  some  rare  instances,  its  ulceration.  By  it  also 
can  be  observed  the  viscid,  mucoid,  or  even  puruloid  secretions, 
issuing  from  the  orifice  of  the  cervix. 

All  this  is  true  and  valuable,  yet,  nevertheless,  innumerable 
mistakes  have  been  made  by  means  of  the  speculum,  A  simple 
increased  redness  of  the  os  and  vaginal  cervix,  which  may  arise 
from  menstrual  engorgement,  from  sexual  excitements,  from 
coitus,  from  displacements  of  the  uterus,  sympathetic  irritations 
from  the  rectum,  bladder,  or  vagina,  or  even  from  mental  and 
moral  causes,  have  been  designated  inflammatory,  and  the  patient 
subjected  to  weeks  or  months  of  treatment,  including  confine- 
ment to  the  couch,  use  of  caustics,  etc.  The  pathologist  so 
engrossed  with  the  persuasion  that  he  cannot  be  mistaken  as  to 
what  he  actually  sees,  has  forgotten  that  there  is  nothing  very 
peculiar,  anatomically,  physiologically,  or  pathologically,  in  the 
mucous  membrane  of  the  cervix  uteri.  Slight  modifications  of 
its  structure  and  its  physiology  impress,  it  is  true,  some  modifi- 
cations of  his  pathology,  but  nothing  that  is  positive  or  peculiar  ; 
nothing  which  demands  any  specific  treatment.  Far  too  much 
credence,  therefore,  has  been  given  to  the  results  of  visual  obser- 
vation, which  have  been  exceedingly  magnified,  and  which  have 
been  productive  of  an  heroic  and  destructive  practice. 

Another  bad  consequence  resulting  from  the  use  of  the  specu- 
lum is  the  false  inferences  made  as  to  the  state  of  the  uterus, 
from  noticing  the  condition  of  the  os,  for  it  seems  to  be  forgotten, 
that  when  an  "  examination  of  the  uterus"  is  said  to  be  made  by 
means  of  the  speculum,  that  the  mere  extremity  of  the  cervix 
and  its  patulous  orifice  is  all  that  is  really  visible,  and  the  infor- 
mation thus  acquired  does  not  indicate  a  pathological  state  of  the 
organ,  nor  does  it  contribute,  in  any  great  degree,  in  such  cases,. 
to  proper  therapeutics. 

So  many  mistakes  in  theory  and  practice  have  resulted  from 
the  use  of  the  speculum,  that  it  would  be  an  interesting  question 
to  determine,  whether  it  has  proved  more  beneficial  or  detri- 
mental in  the  treatment  of  diseases  of  the  uterus. 

Microscopical  and  chemical  observations  of  the  discharges 
from   the  vagina  and    uterus  may  often   throw  light   upon  the 


SYMPTOMS.  143 

nature  of  the  irritation.  From  the  acidity  or  alkalinity  of  the 
secretions,  and  from  the  character  of  the  epithelial  scales,  the 
location  of  the  inflammation,  whether  in  the  vagina  or  uterus, 
may  be  determined.  From  the  peculiarities  of  the  mucus  in  the 
vagina,  in  the  cervix,  or  in  the  body  of  the  uterus,  much  may 
be  learned  as  to  the  location  of  the  disease ;  and  also  whether 
there  be  any  lymph  or  plasma  present,  or  whether  pus  be  mingled 
with  the  discharges,  or  whether  these  be  of  an  entirely  puru- 
lent character,  are  all  circumstances  of  importance. 

There  are  no  positive  "  general  symptoms'''  as  to  the  presence  or 
absence  of  hypertrophy  or  induration  of  the  cervix  or  body  of 
the  uterus.  Hypertrophy  is  by  no  means  uncommon  in  all 
chronic  uterine  affections,  whatever  be  their  pathological  charac- 
ter ;  while  induration,  from  plastic  effusion,  is  more  rare  and  the 
result  of  phlogosis.  Either  state  may  be  suspected,  when  the 
patient,  in  a  standing  position,  complains  of  much  weight  or  pres- 
sure, with  more  or  less  irritation  of  the  bladder  or  rectum.  Still 
these  symptoms  may  often  arise  from  temporary  engorgement  or 
displacement  of  the  uterus.  The  diagnosis  is  established  by 
examination  by  the  touch,  sometimes  assisted  by  external  palpa- 
tion. Thus  the  softness  or  hardness  of  the  tissue  can  be  deter- 
mined ;  the  regularity  of  its  form,  whether  the  enlargement  be 
confined  to  the  anterior  or  posterior  part  of  the  cervix,  or  whether 
the  whole  cervix,  or  the  body  of  the  uterus  be  involved.  The 
size  of  the  uterus  may  be  partially  determined  by  an  internal, 
assisted  by  an  external  examination,  unless  the  patient  be  very 
corpulent.  More  accuracy,  however,  is  obtained  by  means  of 
the  uterine  sound ;  the  length  of  the  cervix  and  that  of  the  cavity 
of  the  organ  may  be  accurately  measured,  and  thus  a  proximate 
idea  can  be  gained  of  the  development  of  the  body  of  the  uterus. 
By  the  touch,  the  degree  of  sensitiveness  present  can  be  ascer- 
tained, and  also  whether  there  be  any  displacement  of  the  organ, 
or  any  pressure  upon  the  adjoining  tissues. 

The  speculum  affords  us  no  assistance  in  determining  the 
nature,  character,  or  development  of  hypertrophy,  or  induration 
of  the  uterus.  Some  advantage  may  occasionally  be  obtained 
by  a  digital  examination  per  rectum,  or  perhaps  sometimes  by 
the  introduction  of  a  catheter  or  sound  into  the  bladder. 

T:\iQprognosis  in  cases  of  endometritis  is  generally  quite  favorable ; 
in  all  the  acute  varieties,  commonly  called  catarrhal  affections,  they 


144  COMPLICATIONS    OF    IRRITABLE    UTERUS. 

are  generally  evanescent  under  tlie  employment  of  simple  reme- 
dies. Chronic  endometritis,  often  the  consequent  of  acute,  is  more 
tedious,  but  we  have  no  hesitation  in  believing,  as  a  general  rule, 
that  it  is  quite  manageable,  time  and  patience  only  being  required. 
Even  in  confirmed  cases,  where  there  is  ectropion  of  the  lips  of 
the  uterus,  and  a  predisposition  to  fungous  growth,  still  no  appre- 
hension need  be  had  as  to  a  favorable  result,  provided  the  disease 
be  not  specific,  and  the  cause  be  carefully  ascertained  and  re- 
moved. 

The  prognosis  in  cases  of  hypertrophy,  according  to  the  princi- 
ples now  laid  down,  is  also  favorable;  for,  as  nervous  or  organic 
irritations  are  the  cause  of  hypertrophy,  therefore  if  such  irrita- 
tions be  removed,  enlargement  will  gradually  disappear,  pre- 
cisely as  the  hypertrophic  condition  of  the  uterus  disappears,  when 
a  polypus  or  a  foetus  has  been  removed  from  its  cavity. 

Favorable  anticipations  also  may  be  entertained,  but  with  more 
reserve  in  indurated  states  of  the  uterus  ;  these  may  be  occasionally 
resolved,  although  the  enlargement  and  induration  usually  remain 
for  life.  Nevertheless,  if  the  displacement  and  irritability  which 
so  generally  result  from  this  condition,  be  removed,  the  patient 
may  enjoy  excellent  health  and  strength. 

The  causes  of  endometritis  are  the  same  as  the  common  causes 
of  acute  inflammation,  such  as  exposures  to  cold,  rheumatism, 
gout,  eruptive  diseases,  and  various  local  irritations.  As  regards 
the  uterus,  the  effects  of  gestation  and  parturition  are  very  fre- 
quently inflammatory,  and  occasionally  endometritis  may  be  ex- 
cited from  sympathy  with  the  surrounding,  or  even  with  distant 
organs. 

Chronic  inflammation  is  very  often  the  result  of  the  acute 
form,  or  supervenes  from  the  local  injuries  so  often  sustained 
during  parturition.  Authors  ascribe  much  of  the  chronic  inflam- 
mation of  the  cervix  to  eruptive  diseases,  v/ith  which  the  patient 
may  be  afflicted;  they  very  generally  assert  that  the  congestions, 
and  excitements  which  accompany  menstruation,  and  the  sexual 
passions,  are  the  cause  of  inflammation.  This  we  cannot  believe; 
all  such  excitations  are  of  a  different  type;  they  are  nervous,  not 
organic.  They  are  followed  by  active  congestions,  it  is  true,  but 
not  by  inflammation ;  and  often  by  abundant  secretions — men- 
strual, leucorrhoeal,  etc.,  by  which  the  patient  becomes  debilitated, 
nervous,  and  exhausted.     "We  have  continually  objected  to  the 


PRESSURE.  145 

idea  that  these  states  of  excitation  are  but  the  primary  stages  of 
inflammation ;  they  have  their  own  morbid  character,  and  their 
own  history  and  terminations.  It  is  doubtful,  also,  whether 
inflammation  of  the  uterus,  or  any  portion  thereof,  is  induced  by 
sympathy  with. the  bladder,  rectum,  ovaries,  etc.  It  may,  from 
these  causes,  become  irritable,  painful,  and  have  its  functions  dis- 
turbed, often  with  more  or  less  increased  secretion,  still  without 
inflammation,  suppuration,  or  alteration  of  tissue. 

It  has  long  been  our  belief  that  inflammations  of  the  os  and 
cervix  arise  more  frequently  from  mechanical  causes  than  from 
any  other  single  source.  Dr.  Wright  has  sanctioned  the  idea 
when  he  speaks  of  pressure  as  a  cause  of  abrasion,  and  even  of  a 
granular  state  of  the  os  uteri.  The  chief  cause  to  which  he 
alludes  is  the  accumulation  of  faeces  in  the  rectum,  causing  pres- 
sure on  the  cervix.  Certainly  every  practitioner  must  acknow- 
ledge this,  who  has  ascertained,  by  examination  per  rectum,  how 
the  neck  of  the  uterus  impinges  against  this  vise  us,  and  reflected 
what  must  be  the  irritation  produced  by  standing,  walking, 
straining,  especially  when  the  rectum  is  distended.  How  often 
will  he  find  his  patients  complaining  of  all  the  symptoms  of 
haemorrhoids  from  this  downward  pressure  of  the  uterus;  and 
also  how  often  will  the  most  exquisite  suffering  be  excited  by 
every  effort  at  defecation.  With  some  patients,  to  receive  an 
enema  into  the  rectum,  or  to  have  a  movement  of  the  bowels,  is' 
dreaded  like  the  act  of  parturition;  agonized  suffering  at  the 
time,  succeeded  by  great  soreness  and  nervous  prostration,  even 
for  many  hours. 

A  more  common  cause  than  the  presence  of  faeces  in  the  rectum, 
is  displacements  of  the  uterus.  All  authors  acknowledge  this  as 
regards  the  os  uteri,  in  cases  of  procidentia  uteri ;  but  it  is  still 
more  common  from  the  constant  pressure  and  attrition  of  the 
cervix  against  the  floor  of  the  pelvis,  in  cases  of  simple  descent 
or  prolapsus.  Authors  have  by  no  means  given  sufl&cient  atten- 
tion to  the  importance  of  this  downward  pressure  of  the  uterus. 
They  have  dwelt  very  learnedly  upon  inflammations  of  the  os, 
on  flexions  of  the  cervix,  and  on  various  deformities  of  the  ante- 
rior or  posterior  lips,  without  observing  that  a  large  majority  of 
these  cases  result  entirely  from  pressure.  The  same  observation 
is  true,  also,  in  a  large  number  of  cases  where  inflammation  is 
found  complicated  with  anteversion  or  retroversion  of  the  uterus. 
10 


146  COMPLICATIONS    OF    IRRITABLE    UTERUS. 

In  our  opinion,  this  fact  explains  why  it  is  that  inflammatory 
affections  of  the  mucous  membrane  of  the  cervix  have  been 
regarded  so  generally  as  peculiar,  as  difficult,  or  even  impossible 
to  treat,  and  why  physicians  have,  in  despair,  abandoned  simple 
therapeutical  measures,  and  resorted  to  caustics,  to  alter  or  de- 
stroy the  condition  of  tissues  which  they  could  not  cure.  Is  it 
not  that  their  remedies  have  been  inefficient,  or  counteracted 
because  they  have  allowed  the  original  cause  to  remain?  The 
continued  pressure  of  the  cervix  against  the  floor  of  the  pelvis 
in  straining,  standing,  walking,  etc.,  continually  keeps  up,  or  re- 
excites  inflammatory  action.  Our  experience,  at  any  rate,  has 
been,  that  by  relieving  the  displacements  in  such  a  way  that 
the  cervix  is  entirely  isolated  from  all  pressure  in  any  direction, 
all  such  inflammatory  actions  have,  with  few  exceptions,  been 
easily  managed;  that  even  in  long  protracted  cases,  where  there 
was  great  tumefaction  at  the  os,  and  also  a  fungous  growth,  a 
cure  has  been  accomplished  without  any  confinement  of  the 
patient,  and  without  any  restriction  as  to  walking  or  other  exer- 
cise, or  any  resort  to  powerful  caustics. 

Pressure  therefore  ought  to  be  regarded,  in  many  instances,  as 
a  primary,  and  often  as  an  aggravating  cause  of  endometritis  of 
the  cervix. 

Endometritis  of  the  lody  of  the  utenis  is  far  less  frequent.  The 
causes  are  chaages  of  temperature,  parturition,  the  presence  of 
tumors  in  the  cavity  or  body  of  the  uterus,  and  the  extension  of 
inflammatory  affections  of  the  cervix  to  the  mucous  membrane 
of  the  body  by  continuity  of  tissue.  Certain  eruptive  diseases 
and  general  febrile  states  of  the  patient  are  usually  included 
among  the  causes. 

The  causes  of  hypertrophy  of  the  uterus  are,  as  has  been  frequently 
intimated,  various.  This  enlargement  is  often  the  result  of  defi- 
cient "  involution  of  the  uterus"  after  delivery.  It  is  frequently 
the  consequence  of  the  engorgements  arising  from  displacements 
of  the  uterus,  from  inordinate  sexual  passions  and  indulgences; 
from  the  presence  of  polypi  or  other  tumors  in  the  cavity  or 
body  of  the  uterus :  from  great  ovarian  irritations,  and  occasion- 
ally it  is  one  of  the  sequelae  of  inflammations  of  the  mucous 
membranes  of  the  cervix  or  body  of  the  uterus. 

Proper  induration  of  the  cervix  or  body  of  the  uterus  has,  in- 
deed, but  one  general  cause — inflammation — whatever  may  have 


PELVIC    PERITOXITIS.  147 

been  the  original  source  of  the  inflammatory  action :  great  care, 
however,  should,  be  taken  to  determine  whether  the  inflammation 
has  subsided,  and  not  to  confound  the  morbid  sensibility  of  the 
indurated  uterus,  so  often  perceptible,  with  inflammatory  action, 
as  the  former  may  be  present,  and  even  excessively  great,  while 
the  latter  has  entirely  disappeared. 

Pelvic  Peritonitis. — There  is  still  another  variety  of  these 
inflammatory  affections  of  the  uterus,  where  the  phlogosis  is  fixed 
chiefly  in  the  peritoneal  covering  of  the  organ,  and  hence  termed 
'''■peri-uterine'''  or  "'pelvic  peritonitis^ 

The  inflammatory  affections  incident  to  women  in  child-birth 
have  been  usually  treated  under  the  name  of  puerperal  fever. 
Modern  pathologists  have  analyzed  these  complaints,  which  are 
now  often  arranged,  under  distinct  heads,  such  as  puerperal  peri- 
tonitis, ovaritis,  metritis,  etc.  When  the  disease  is  violent,  all 
these  tissiies  are  often  found  involved  in  the  inflammatory  pro- 
cess ;  and  post-mortem  it  is  difficult  to  determine  which  tissue  or 
organ  was  originally  affected.  Occasionally  the  disease  is  more 
localized,  so  that  even  during  life,  the  diagnosis  could  be  estab- 
lished between  one  and  the  other  form  of  complaint. 

In  chronic  inflammation,  however,  the  distinguishing  marks 
can  be  more  readily  detected,  although,  in  most  cases,  the  diag- 
nosis, as  to  the  location  of  the  disease,  must  remain  doubtful, 
notwithstanding  the  skill  and  positive  assertions  of  different 
practitioners.  By  most  pathologists  pelvic  irritations  are  referred 
chiefly  to  the  uterus.  Mr.  Tilt  has  warmly  contended  that  ova- 
ritis is  very  frequently  the  chief  trouble,  while  lately,  in  1867, 
M.  Berniitz  endeavors  to  fix  attention  on  "  pelvi-peritonitis,"  to 
which  most  of  the  uterine  disorders  are  referable.  Still,  he  af&rms 
that  this  peritoneal  inflammation,  although  sometimes  resulting 
from  acute  forms  of  the  disease,  is  generally  the  sequel  of  uterine 
affections ;  for  example,  he  refers  much  to  the  retention  of  the 
menses,  contending  that  if  they  be  not  readily  excreted  as  ob- 
served in  dysmenorrhoea,  or  if  they  be  retained  from  obstructions 
in  the  cervix,  the  uterus  and  Fallopian  tubes  will  become  distended 
and  irritated,  effusion  of  the  fluid  may  occur  into  the  peritoneum, 
and  thus,  or  by  continuous  inflammation  from  the  mucous  mem- 
brane of  the  uterus  and  tubes,  peritonitis  will  be  excited.  This, 
he  infers,  because,  in  most  post-mortem  examinations,  inflamma- 


148  COMPLICATIONS    OF    IKRITABLE    UTERUS. 

tions  of  the  mucous  membrane  of  tlie  extremity  of  the  tubes  has 
been  observed.  We  cannot  ourselves  give  much  credence  to  this 
explanation;  for  dysmenorrhoea  is  one  of  the  most  frequent  of 
female  diseases,  while  retention  of  the  menses  from  obstruction 
is  one  of  the  most  rare  accidents  in  the  economy.  When  noticed 
by  authors  they  describe  the  fluid  as  being  retained  in  the  uterus, 
which  becomes  greatly  enlarged,  even  for  months,  and  may  be 
eventually  discharged  by  a  surgical  operation  without  any  effusion 
having  occurred,  or  any  peritoneal  inflammation.  It  is  said,  that 
in  some  few  instances,  the  menses  have  escaped  through  the  Fal- 
lopian tubes  into  the  peritoneum,  constituting  one  of  the  varieties 
of  hsematocele,  which  is  not  necessarily  followed  by  inflammation. 

M.  Berniitz  also  traces  this  peritonitis  to  blennorrhagia,  to  me- 
norrhagia,  to  inflammations  of  the  cavity  of  the  uterus  (sometimes 
excited  by  the  uterine  sound),  and  which,  by  continuous  tissue, 
passes  along  the  Fallopian  tubes  to  the  peritoneum.  Sometimes 
it  results  from  ovaritis,  and  d.oubtless  also  occasionally  from  me- 
tritis, the  inflammation  spreading  from  the  tissues  of  the  uterus 
to  its  investing  membrane.  Although  M.  Berniitz  thus  refers 
peritonitis  very  generally  to  uterine  disease,  yet  he  considers  it  as 
of  primary  importance.  In  this,  also,  we  believe  there  must  be 
some  mistake  ;  for  every  one  is  familiar  with  the  frequency  of  the 
irritable  and  inflammatory  diseases  of  the  uterus  of  a  chronic 
character,  and  yet  it  is  almost  the  universal  experience  that  the 
decided  symptoms  of  peritonitis  are  rarely  developed ;  and,  more- 
over, that  death  seldom  results,  and  hence  the  question  as  to  the 
exact  pathology  can  scarcely  ever  be  tested  by  post-mortem  exa- 
minations. All  this  is  in  opposition  to  the  theory  of  peritonitis, 
which,  it  is  well  known,  is  frequently  fatal ;  while,  under  treatment 
directed  to  the  uterus,  recoveries  are  very  numerous.  Hence,  we 
must  infer  that  the  cases  reported  by  M.  Berniitz  are  exceptional, 
occurring  in  broken-down  constitutions,  in  scrofulous,  cachectic, 
or  syphilitic  patients,  although  there  can  be  no  doubt  that  occa- 
sionally peritonitis  exists  as  a  consequence  of  the  puerperal  state, 
resulting  from  ovaritis  or  metritis ;  yet,  in  ordinary  practice,  it  is 
comparatively  very  rare,  while  nervous  irritations  of  the  uterus 
and  endometritis  are  of  frequent  occurrence. 

The  progress  of  chronic  pelvic  peritonitis  is  often  slow,  and 
may  terminate  occasionally  in  resolution ;  more  frequently  in  the 


PELVIC    PERITONITIS.  149 

effusion  of  lymph,  and  the  consequent  adhesion  of  the  peritoneal 
surfaces.  This  is  comparatively  favorable.  Seroid  or  purulent 
effusions  may,  however,  ensue :  it  is  possible  for  the  patient  then 
to  recover,  these  fluids  gradually  disappearing;  but  generally, 
symptoms  either  of  dropsy  or  of  hectic  fever  supervene,  followed 
by  prostration  and  death.  In  other  instances  ulceration  may  ensue, 
so  that  the  pus  is  discharged  into  the  intestines,  into  the  vagina, 
or  even  externally  through  the  skin,  occasionally  followed  by 
recovery.  Sometimes,  especially  when  the  pus  is  not  completely 
evacuated,  abscesses  continue  to  re-form,  or  atmospheric  air  finds 
admission,  causing  putrefaction,  and  thus  hastening  the  fatal  pro- 
gress of  the  disease. 

These  purulent  collections  have  been  described  by  M.  Nonat, 
says  M.  Berniitz,  under  the  name  of  "peri-uterine  phlegmons,"  to 
which  he  very  justly  objects,  as  no  proper  inflammatory  tumor 
can  be  detected,  or  indeed  can  exist,  owing  to  the  close  attachment 
of  the  peritoneum  to  the  uterus.  When  a  tumor  is  occasionally 
perceived  towards  the  neck  or  sides  of  the  uterus,  it  is  the  result 
of  a  thickening  of  the  tissues,  or  a  purulent  collection;  and,  when 
felt,  should  be  carefully  distinguished  from  haematocele,  displaced 
ovaries,  and  other  pelvic  tumors.  It  is  almost  impossible,  also, 
excepting  perhaps  from  the  history  of  the  case,  to  determine 
whether  these  abscesses  were  originally  situated  in  the  perito- 
neum, or  in  the  areolar  tissues  connecting  the  peritoneum  with 
the  pelvic  viscera — the  result,  therefore,  of  cellulitis ;  and  prac- 
tically, perhaps,  it  is  of  little  importance,  as  the  matter,  once 
formed,  pursues  a  similar  course  and  demands  similar  treatment. 

Symptoms. — It  is  very  evident,  from  what  has  been  said,  that 
the  symptoms  of  chronic  peritonitis  must  be  exceedingly  obscure. 
Most  pathologists  ignore  its  existence,  except  in  a  few  instances, 
and  these  generally  being  the  result  of  puerperal  peritonitis.  M. 
Berniitz  himself  acknowledges  not  merely  the  difficulty  of  diag- 
nosis, but  that  most  pathologists  regard  this  reputed  peritonitis 
as  being  truly  a  uterine  disease.  He  thinks  that  hysteralgia,  or 
irritable  uterus,  which  we  and  others  regard  as  a  very  common 
complaint,  is  very  rare,  believing  that  most  of  the  supposed  cases 
of  irritable  uterus  are  specimens  of  peritonitis  ;  also,  cases  of  en- 
dometritis he  would  often  refer  to  inflammations  from  the  serous 
investment  of  the  uterus.  The  symptoms,  therefore,  in  the  earlier 
stages,  are  those  common  to  pelvic  irritations.     If,  however,  the 


150  COMPLICATIONS    OF    IRRITABLE    UTERUS. 

pain  be  very  permanent,  always  aggravated  by  pressure,  with 
more  or  less  tympanites,  and  especially  if  there  be  febrile  excite- 
ment, suspicions  may  be  ent^ertained  that  the  peritoneum  is  in- 
volved; still,  much  allowance  must  be  made  for  the  rapid,  irritable 
pulse  of  nervous  patients,  and  for  the  hypergesthetic  condition  of 
the  skin  and  other  tissues  in  hysteric  women,  where  there  is  no 
proper  inflammation  or  fever. 

In  the  later  stages  of  the  disease  the  symptoms  may  be  more 
positive,  as  then  great  debility,  emaciation,  with  hectic  fever,  may 
be  observed.  On  digital  examination  per  vaginam,  the  pelvic 
tissues  may  be  found  unusually  full  or  thickened,  sometimes  more 
in  one  spot,  especially  about  the  sides  of  the  uterus,  than  others, 
resembling  somewhat  a  phlegmon,  but  more  soft  and  "boggy," 
and  occasionally  fluctuation  even  may  be  detected,  when  pus  has 
actually  formed;  still,  as  every  practitioner  knows,  all  these,  says 
M,  Berniitz,  are  very  doubtful  indications,  requiring  much  tact 
and  experience.  This  fulness  of  the  tissues,  swellings,  etc.  may 
be  the  result  of  hsematocele,  cellulitis,  cysts  of  the  ovaries,  dis- 
placements of  the  uterus,  or  fibrous  tumors  of  the  organ,  and 
even  of  uterine  engorgements. 

In  some  rare  cases,  fluctuation  may  be  perceived  where  the 
tissues  are  thinned,  and  where  there  is  a  disposition  to  rupture ; 
generally,  however,  in  such  cases  the  rupture  takes  place  and  the 
matter  is  discharged,  partially  or  completely,  before  even  suppu- 
ration had  been  suspected. 

To  assist  in  the  diagnosis  in  the  different  varieties  of  pelvic 
tumors,  the  needle  has  been  employed,  by  which  to  determine 
not  merely  whether  the  swelling  be  solid  or  encysted,  but  also  to 
indicate,  as  far  as  practicable,  the  character  of  the  contents.  We 
cannot  regard,  however,  these  explorations  as  perfectly  safe  in 
these  diseased  states,  as  often  some  of  the  enlarged  bloodvessels 
may  be  penetrated,  or  the  peritoneum  may  be  punctured,  or  even 
inflammation  set  up  in  the  swelling.  Hence,  great  care  should 
be  taken  as  to  the  direction  in  which  the  needle  is  passed,  and  to 
the  prevention  of  any  subsequent  irritation  or  inflammation. 

Although  we  have  thought  it  right  thus  to  notice  the  opinions 
of  M.  Berniitz  and  others,  we  have  had  little  or  no  experience  of 
local  peritonitis  simulating  uterine  disease ;  at  any  rate,  we  have 
not  recognized  its  existence,  but  have  very  uniformly  relieved 
our  patients  by  attention  to  the  disease  of  the  uterus,  without 


RESULTS    OF    INFLAMMATION.  151 

reference  to  that  of  the  peritoneum.  In  one  case  only  do  we 
remember  a  patient  dying  of  peritonitis,  which  probably  resulted 
in  her  case  from  ovaritis,  and  it  may  be  from  rupture  of  a  Grraafian 
vesicle. 

Irritahility  after  Inflammation. — Finally,  it  is  a  fact  of  great 
importance,  that,  after  metritis  of  the  cervix  or  the  corpus  uteri 
has  subsided,  the  tissues  often  remain  indurated,  heavy,  and  en- 
larged. If  the  patient  prematurely  arises  from  her  bed  under 
these  circumstances,  or  if  she  has  not  been  quite  prudent,  in 
every  respect,  many  of  the  apparent  symptoms  of  inflammation 
will  return,  and  often  remain  obstinate  for  months  or  years,  in 
opposition  to  all  the  usual  appliances  for  the  amelioration  of 
inflammatory  complaints.  In  other  words,  this  enlarged,  indu- 
rated organ  is  now  free  from  all  inflammation,  and  is  simply  in 
a  state  of  nervous  irritation.  It  is  an  irritable  uterus  demanding 
no  longer  antiphlogistic  remedies,  but  an  opposite  course  of  treat 
ment.  The  same  observations  may  be  made  as  regards  the  con- 
dition of  the  uterus  in  many  cases  after  parturition,  where  there 
is  defective  involution,  connected,  as  supposed,  with  fatty  degene- 
ration. This  state  is  often  termed  inflammatory ;  where  the  pro- 
gress of  involution  has  been  arrested  by  some  cause,  the  organ 
remaining  large,  hypertrophied,  and  indurated,  sensitive  or  irri- 
table, but  still  no  actual  inflammation  present. 

Such  are  the  leading  facts,  respecting  the  essential  character  of 
the  inflammatory  affections  of  the  uterus,  without  tracing  them 
to  their  remote  consequences — fungous  growths,  disorganization, 
gangrene,  and  sphacelus.  With  the  symptoms  of  inflammation, 
will  often  be  conjoined  the  pains,  the  burning,  the  pressure,  the 
weight,  the  bearing  down,  the  cramp,  the  spasms,  the  peculiar 
discharges,  and  the  whole  tribe  of  wretched  nervous  sensations, 
to  which  allusion  has  already  been  made. 

Errors  in  Theory  and  Practice. — Except  in  cases  of  acute 
inflammation  of  the  uterus  arising  from  contusions,  wounds,  pain- 
ful and  difficult  labors,  from  exposure  to  cold,  from  rheumatism, 
gout,  etc.,  where  all  will  acknowledge  that  the  case  is  purely 
inflammatory,  and  to  be  treated  accordingly ;  it  will  often  be 
difficult,  and  sometimes  impossible,  so  fully  to  analyze  the  symp- 
toms of  uterine  irritations,  as  to  establish  a  correct  pathology, 


152  COMPLICATIONS    OF    IRRITABLE    UTERUS. 

and,  of  course,  the  proper  therapeutical  indications.  We  allude 
now,  chiefly,  to  chronic  inflammations  of  the  cervix  uteri. 

The  natural  and  perhaps  almost  universal  inference  is,  that 
such  cases  are  purely  inflammatory,  thence  destructive ;  and  that 
ulceration  and  disorganization  will  be  the  result  if  the  disease  be 
not  arrested.  Therefore  they  are  often  treated  by  rest,  by  evacu- 
ants  (internal  and  external),  by  revulsives,  by  astringents,  by 
caustics.  The  more  obstinate  the  symptoms,  the  more  powerful 
the  caustic  tried ;  so  that,  from  a  solution  of  the  nitrate  of  silver 
to  the  actual  cautery,  escharotics  of  every  intensity  have  been 
employed. 

Is  there  not  here  some  radical  mistake  ?  Can  it  be  that  sim- 
ple inflammation  of  the  neck  of  the  cervix,  where  there  is  no 
specific  irritation,  no  tendency  to  malignancy,  where  the  cause  is 
no  longer  operative,  is  thus  indomitable,  and  so  difficult  to  arrest  ? 
Must  months  and  years  expire  ?  will  ordinary  measures  fail  ?  Is 
there  anything  so  peculiar  in  the*  structure  of  the  mucous  or 
parenchymatous  tissues  of  the  uterus  as  to  render  their  inflam- 
matory affections  so  obstinate,  so  difficult  to  manage  ? 

If  the  appeal  be  made  to  the  experienced  practitioner  of  ob- 
stetrics, he  would  certainly  and  unhesitatingly  give  the  negative 
answer  to  all  these  questions.  He  has  become  too  familiar  with 
inflammations  of  the  vagina,  of  the  os  and  cervix  uteri,  as  the 
result  of  contusions,  lacerations,  and  wounds  received  in  labor; 
he  has  met  too  many  cases  of  injuries  sustained  in  cases  of  rupture 
of  the  OS  uteri,  not  to  know  that  in  a  large  majority  of  such 
patients  no  serious  ill  results,  provided  the  general  system  is  in 
a  good  state,  and  the  inflammation  not  so  intense  as  to  endanger 
gangrene.  When,  also,  in  the  unimpregnated  state  operations 
have  been  performed,  wisely  or  unwisely,  by  the  knife ;  recove- 
ries, so  far  as  the  mere  inflammation  of  the  tissues  is  concerned, 
are  confidently  anticipated. 

The  same  is  true  from  the  common  practice  of  applying  caus- 
tics. The  advocates  for  the  knife  and  for  the  caustic  are  careful 
to  insist  that  there  will  be  no  bad  results ;  the  ulcers  thus  pro- 
duced will  heal  up  readily,  and,  in  a  few  days,  or  weeks  at 
farthest,  they  regard  the  patient  as  well  prepared  for  a  renewal 
of  the  operation.  Why  then  is  this  not  true  of  the  original 
inflammation  existing  in  the  same  tissues,  in  the  same  patient, 
and   under  precisely  the  same   circumstances,  with   the   single 


ERRORS    IN    THEORY    AND    PRACTICE.  153 

exception  that  the  one  set  arises  from  artificial  measures,  and  the 
other  from  causes  unknown,  or  difficult  to  ascertain,  and  hence 
termed  spontaneous  ?  The  very  theory,  and  of  course  the  excuse 
for  these  terrible  operations  is  the  supposed  incurability  of  inflam- 
mation, or  even  that  there  is  something  peculiar  or  specific  in 
inflammatory  action,  which  would  be  very  difficult,  if  not  im- 
possible to  substantiate. 

There  must  be  some  error  in  theory,  leading  to  error  in  prac- 
tice. Judging  from  our  own  experience,  the  error  is  twofold  ;  one 
arising  from  a  want  of  full  investigation  as  to  the  original  and 
accessory  causes ;  and  the  other,  from  attributing  all  the  symp- 
toms to  congestion,  inflammation,  ulceration,  etc.,  while  many 
depend  on  nervous  irritation  simply.  We  have  already  detailed 
the  causes  of  chronic  endometritis,  and  dwelt  particularly  on  the 
fact  that  pressure  on  the  cervix  uteri,  in  consequence  chiefly  of 
displacements,  is  one  of  the  most  important  of  the  causes  either 
original  or  secondary  and  accessory.  This  pressure  is  always 
present,  perhaps  even  in  the  recumbent  position,  and  is  greatly 
aggravated  by  standing,  walking,  straining,  etc.  It  is  often  so 
great  that  flexions  and  other  deformities  of  the  cervix  are  induced ; 
and  we  have  no  doubt  that  it  often  excites  organic  irritation,  and, 
of  course,  will  aggravate  such  inflammation  when  present.  This, 
in  our  judgment  at  least,  is  sufficient  often  to  counteract  the 
best  directed  remedies,  and  render  a  simple  inflammation  per- 
sistent. A  cause  of  mischief  is  always  present,  just  as  a  minute 
quantity  of  pus,  accumulating  in  a  fistula,  prevents  its  healing,  in 
opposition  to  the  washes  and  caustics  of  the  inattentive  surgeon. 

The  second  and  more  influential  error  is  the  not  distinguishing 
between  the  symptoms  due  to  inflammation,  and  those  due  to 
nervous  irritation ;  in  not  recognizing  the  existence,  as  already 
pointed  out,  of  pure  uncomplicated  cases  of  irritability.  This  has 
been,  and  still  is,  a  very  universal  error. 

In  practice  it  is  often  forgotten  that  pain,  although  frequently 
associated  with  inflammation,  does  by  no  means  necessarily  im- 
ply the  existence  of  inflammatory  disease.  If  this  be  remem- 
bered, it  will  cause  no  surprise  that  the  pain,  the  burning  and 
pulsatile  sensations,  even  the  turgescence  of  the  tissues  often  exist, 
as  has  been  already  detailed,  from  pure  nervous  irritation,  when 
there  is  no  inflammation  whatever  present.  Hence,  in  cases  of 
chronic  phlogosis,  the  above  symptoms  are  not  referable  to  the 


154  COMPLICATIONS    OF    IRRITABLE    UTERUS. 

organic,  as  much  as  to  tlie  nervous  irritation.  And  on  tlie  other 
hand,  we  know  that  severe  and  destructive  inflammation  may  exist 
with  very  trifling  pain. 

May  it  not,  therefore,  be  legitimately  inferred,  in  many  cases 
at  least,  where,  with  acknowledged  symptoms  of  inflammation, 
there  exists  great  pain  in  the  back,  abdomen,  extremities,  spine, 
head,  etc.,  that  such  sufferings  are  the  result  not  so  much  of  in- 
flammation as  of  nervous  irritation,  and  that  the  treatment  for 
the  former,  although  to  a  certain  extent  necessary,  so  far  from 
being  adequate  for  the  latter,  may  prove  detrimental?  The  gene- 
ral symptoms  of  uterine  irritation,  and  the  results  of  therapeutical 
observation,  to  which  reference  will  soon  be  made,  confirm,  we 
think,  this  logical  inference. 

Our  experience  abounds  in  proof  of  this  principle.  For  many 
years  patients,  complaining  of  great  suffering,  have  continually 
presented  themselves  as  the  subjects  of  inflammatory  or  ulcera- 
tive complaints,  where  no  such  lesions  could  be  discovered,  nor 
any  evidence  of  their  having  existed.  Again,  many  have  come, 
who  had  been  treated  for  phlogosis  by  all  the  variety  of  evacuant 
and  revulsive  remedies,  by  astringent  lotions  and  caustics,  with 
perfect  success  as  reported  by  their  medical  attendants ;  the  inflam- 
mation had  disappeared,  the  ulcers  had  healed ;  nevertheless,  the 
miserable  sensations  of  pain,  uneasiness,  debility,  and  wretched- 
ness still  continued.  Again,  in  others,  some  inflammation  of  the 
mucous  tissue  still  existed,  and  under  the  antiphlogistic  treatment 
had  continued  persistent.  Such  inflammatory  affections  we  have 
almost  disregarded,  and  have  employed  no  remedies  but  lotions 
of  water,  or  of  simple  astringents,  and  paid  immediate  attention  to 
the  nervous  irritation  of  the  uterus  (especially  by  removing  the 
cause,  whether  original  or  aggravating)  with  the  happiest  results 
as  respects  both  the  animal  and  organic  disturbances.  The  pain 
and  uneasiness  disappear,  and  soon  no  trace  of  inflammation  can 
be  found. 

Tractability  of  these  Inflammations. — Such  cases  as  these, 
years  ago,  brought  us  to  the  conclusion  that  inflammations  of  all 
mucous  membranes,  ^^  cseteris  j^aribics,^^  making  allowances  for  par- 
ticular locations  (the  larynx,  for  example)  and  particular  func- 
tions, are  the  most  simple  and  tractable  of  inflammatory  complaints. 
The  local  symptoms  are  moderate,  the  general  sympathies  are  but 


THEIR    TRACTABILITY.  155 

slightly  disturbed,  the  consequences  are  not  often  detrimental,  and 
the  treatment  is  not  usually  difficult.  Compare  bronchitis  with 
pleuritis  or  pneumonia,  gastro-enteritis  with  peritonitis  or  hepa- 
titis, etc.  So  also  vaginitis  and  endometritis  are,  we  must  believe, 
equally  mild  and  manageable  complaints  when  compared  with 
inflammations  of  the  substance  or  of  the  peritoneal  surface  of  the 
uterus. 

We  go  further,  and  say  that  even  in  those  chronic  inflammations 
of  the  cervix  involving  the  whole  substance  of  the  neck,  with  the 
granular  appearance  of  its  extremity,  and  the  everted,  tense, 
tumid  lips  of  the  os,  few  symptoms  exist  to  advertise  the  patient 
of  her  condition,  and  very  often  no  general  disturbances  are 
excited.     The  patient  often  feels  well. 

The  reputed  intractability  of  these  inflammations  often  arises 
from  their  complication  with  displacements,  which  keep  up  the 
irritation. 

Case. — A  lady  is  now  under  treatment,  who,  for  a  year  past, 
has  been  miserable  and  unable  to  move  with  comfort.  She  has 
been  languid  and  indisposed  to  all  kind  of  mental  or  ph3^sical  efibrt ; 
and  complained  of  a  constant,  dull  pain  in  the  sacral  region,  and 
also  above  the  right  groin,  often  in  the  groin  and  down  the  inside 
of  the  thigh  on  the  same  side,  and,  especially  on  motion,  of  a  severe 
neuralgic  pain  in  the  right  hip  behind  the  trochanter.  In  addition 
she  had  menorrhagia,  the  flow  recurring  every  three,  sometimes 
every  two  weeks ;  and  also  frequent  sanguineous  vaginal  discharges 
with  coagula,  so  that  she  was  seldom  entirely  free  from  a  regular 
or  irregular  sanguineous  flow.  She  had  not  been  conscious  of  a 
white  discharge  at  any  time.  She  had  a  good  appetite,  good  diges- 
tion, regular  bowels,  looked  well,  and  was  quite  fleshy,  especially 
for  a  lady  of  thirty-five,  the  mother  of  several  children.  On  vagi- 
nal examination,  the  neck  of  the  uterus  was  found  to  be  indurated 
and  enlarged,  at  least  twice  its  natural  size ;  the  edges  of  the  os 
were  separated  and  everted,  the  os  rather  contracted,  and  in 
several  places  there  was  so  much  stony  induration  as  to  suggest 
the  idea  of  scirrhus,  especially  as  the  mucous  surface  of  the  os 
tincse  was  rather  prominent,  partly  soft,  and  bleeding  at  the 
slightest  touch.  The  uterus  was  hard  and  enlarged,  its  longitu- 
dinal diameter  being  some  three  and  a  half  inches.  The  whole 
organ  was  prolapsed  with  a  tendency  to  retroversion.  Unmis- 
takable  signs   of  local   inflammation  were   present  threatening 


156  COMPLICATIONS    OF    IRRITABLE    UTERUS. 

fungous  disorganization,  and  the  use  of  lunar  caustic  and  of 
iodine  was  resorted  to  in  addition  to  suitable  emollient  waslaes. 
We  had  no  hesitation,  after  the  second  or  third  visit,  to  attempt 
the  restoration  of  the  womb  to  its  natural  position ;  so  as  to 
relieve  this  organ  and  the  sacral  nerves,  etc.,  from  the  nervous 
irritation,  which  seemed  to  us  superadded  to  those  of  the  organic 
or  inflammatory  irritation.  This  was  done  with  the  happiest 
results ;  the  patient  was  almost  entirely  relieved  of  the  pelvic 
pains ;  could  stand,  and  walk,  and  drive  with  comfort.  There 
was  also  a  great  amelioration  of  the  hemorrhagic  symptoms,  and, 
of  course,  of  her  nervous  and  mental  wretchedness.  She  at  once 
considered  herself  as  comparatively  well.  Yet  the  local  disease, 
although  better,  still  remains  after  two  months'  perseverance  in 
treatment,  and  will,  doubtless,  continue  for  weeks  if  not  for 
months  to  come. 

Upon  this  principle  we  have  continually  acted  in  analogous 
affections  for  years  past,  with  the  best  possible  results. 

Treatment  of  Metritis^  and  its  Varieties. — Little  may  be  said  of  the 
treatment  of  the  acute  forms  of  metritis.  All  practitioners  are 
united  in  the  opinion  that  local,  and,  in  most  instances,  general 
antiphlogistic  remedies  are  absolutely  necessary,  great  attention 
being  paid,  however,  to  those  modifications  resulting  from  the 
original  cause  and  from  the  ever  varying  condition  of  the  patient's 
system. 

In  the  treatment  of  chronic  inflamraatinn^  however,  there  is  great 
discrepancy  of  opinion  ;  the  general  system  occasionally  demands 
some  anti-febrile  remedies,  such  as  mild  laxatives,  diaphoretics, 
and  diuretics.  Generally,  however,  the  symptoms  indicate  the 
employment  of  tonics,  owing  to  the  loss  of  appetite,  and  the 
debility  which  usually  is  present. 

These  tonics  may  be  varied  indefinitely  according  to  the  suscep- 
tibilities of  the  patient,  her  former  experience,  and  the  observation 
of  the  practitioner :  suffice  it  to  observe  at  present,  that  we  have . 
usually  found  that  a  combination  of  mineral  and  vegetable  tonics 
proves  more  efficient  in  exciting  the  proper  appetite  and  digestion, 
and  in  giving  tone  to  the  general  system,  than  either  alone. 

We  will  refer  the  reader  to  the  general  treatment  of  irritability 
of  the  uterus  for  observations  on  the  use  and  abuse  of  narcotics 
and  stimulants  in  all  these  cases  of  nervousness  with  apparent 
or  real  debility  of  the  system.     The  management  of  the  general 


TREATMENT    OF    CHRONIC    INFLAMMATION.  157 

system  will  be  precisely  the  same  whether  local  inflammation 
be  present  or  absent,  whether  it  be  a  case  of  organic  or  nervous 
irritation. 

Local  antiphlogistic  remedies,  in  some  form,  are  all  important 
in  the  treatment  of  metritis. 

In  endometritis  of  the  cervical  portion,  if  there  be  any  acnte 
symptoms  present,  as  manifested  by  pain,  great  turgescence  and 
vascularity  of  the  tissues,  loss  of  some  blood  by  leeches  to  the 
hypogastrium,  to  the  pudendum,  to  the  vagina,  or  directly  to  the 
cervix  may  prove  advantageous :  sometimes  scarifications  may  be 
employed  as  a  substitute.  Laxative  medicines,  or  warm  laxative 
enemata,  are  all  important,  while  warm  hip  baths,  warm  poultices 
to  the  hypogastric  region  and  to  the  pudendum,  will  prove  very 
soothing  and  relaxing.  Few  things  contribute  more  to  the  com- 
fort of  the  patient  than  warm  flaxseed  or  other  mucilages  thrown 
into  the  vagina,  carefully,  so  as  not  to  irritate  the  cervix.  These 
may  be  repeated  two  or  three  times  a  day.  Dr.  Thomas,  of  New 
York,  indorses  the  observations  of  Dr.  Sims  that  glycerine  in- 
troduced into  the  vagina  on  pledgets  of  cotton  or  lint  will  operate 
as  a  "  hydragogue,"  causing  an  increase  of  the  fluid  evacuations 
from  the  tissues.  All  these  remedies  operate  upon  the  general 
principle  of  increasing  the  secretions,  especially  from  the  vagina 
and  cervix,  and  thus  promoting  the  natural  tendency  of  mucous 
surfaces  to  resolution.  In  such  cases,  perfect  rest  in  the  recumbent 
position  should  be  carefully  maintained,  and  all  attempts  to  strain, 
or  bear  down,  should,  on  all  occasions,  be  avoided. 

When  the  inflammatory  action  has  become  moderate  and 
especially  in  the  chronic  forms  of  the  disease,  as  it  is  usually  pre- 
sented to  the  practitioner,  the  above  plan  must  be  much  modified; 
warm  injections  may  be  continued  so  long  as  there  is  much  pain 
or  they  may  be  pleasant  to  the  sensations  of  the  patient,  but  gradu- 
ally the  temperature  should  be  lowered,  so  that  cool,  or  even  cold 
vaginal  and  rectal  enemata  may  be  used.  These  are  useful  as  an 
antiphlogistic  remedy,  and  also  as  giving  tone  to  the  relaxed 
tissues,  having  a  tendency  also  to  diminish  the  vascular  excitement, 
and  thus  the  leucorrheal  discharges. 

The  removal  of  the  cause  here  as  in  all  cases  of  inflammation 
is  the  all  important  indication,  and  one,  we  have  already  intimated 
as  having  been  greatly  neglected  in  uterine  affections. 

General  causes,  whether   rheumatic,   gouty,  febrile,  simple,  or 


158  COMPLICATIONS    OF    IREITABLE    UTERUS. 

eruptive,  are  to  be  counteracted.  The  removal  of  hard  faeces  from 
the  rectum,  colon,  etc.,  should  be  accomplished  by  mild  laxatives 
or  enemata,  all  bearing  down  being  strictly  forbidden.  Other  local 
causes  of  irritation,  as  haemorrhoids,  ascarides  in  the  rectum  or 
vagina,  or  any  foreign  bodies  in  this  canal  which  may  press 
upon  the  cervix,  or  any  sympathetic  irritations,  should  be  avoided, 
as  well  as  all  marital  intercourse,  or  any  improper  excitation  of 
the  passions. 

When  speaking  of  the  causes  of  endometritis,  we  dwelt  much 
on  the  importance  of  pressure  against  the  cervix,  resulting  from 
the  weight  of  a  hypertrophied  or  indurated  uterus  and  also  from 
its  various  displacements,  especially  prolapsus  and  retroversion  of 
the  organ.  We  insisted  also  that  much  of  the  indomitable  char- 
acter ascribed  to  these  inflammations  is  owing  to  the  continuation 
of  this  pressure,  practitioners  contenting  themselves  with  anti- 
phlogistic measures,  while  their  efforts  were  continually  counter- 
acted by  the  pressure  to  which  the  inflamed  tissues  were  con- 
stantly subjected.  We  have,  therefore,  for  very  many  years, 
acted  upon  the  principle  that  such  pressure  was  to  be  counteracted, 
and  we  are  acquainted  with  no  method  of  fulfilling  this  indication, 
but  by  means  of  some  variety  of  a  ring  pessary.  This,  we  know,  is 
in  opposition  to  the  universal  opinion  of  the  profession ;  but  the 
principle  is  so  clear,  so  in  accord  with  the  surgical  treatment  of 
inflammations  in  every  part  of  the  body,  and  so  fully  confirmed 
by  our  personal  experience,  that  we  must  maintain  its  propriety. 

The  simple  idea  is  to  isolate  the  cervix  uteri  from  all  contact, 
or,  at  any  rate,  from  all  pressure  of  the  surrounding  tissues.  A 
ring  pessary,  therefore,  of  such  a  form  as  to  obviate  the  peculiar 
displacement  existing,  and  so  large  as  that  the  neck  of  the  uterus 
passes  through  its  opening,  will  support  the  body  of  the  organ 
while  the  cervix  is  liberated  from  friction ;  the  weight  of  the 
superincumbent  organ  increased  by  the  pressure  of  the  intestines 
and  abdominal  muscles  is  all  received  by  the  lower  part  of  the. 
uterus,  which  is  supported  by  the  pessary. 

To  fulfil  this  indication,  of  course,  much  judgment,  perhaps 
skill  and  experience,  are  demanded;  the  ring  should  not  be  too 
small,  for  fear  that  it  should  rotate  in  the  vagina,  or  actually 
come  away,  irritating  the  cervix.  Neither  should  it  be  too  large, 
nor  press  in  a  wrong  direction,  for  fear  the  vagina,  the  uterus, 
the  bladder,  or  the  rectum  might  be  disturbed,  or  even  inflamed 


TREATMENT    OF    CHRONIC    INFLAMMATION.  159 

Wlien  properly  adjusted,  the  uterus  should  be  found  in  its  natu- 
ral position,  with  the  fundus  inclined  somewhat  forward,  and  the 
cervix  and  os  backward,partially  projecting  through  the  opening 
of  the  ring.  A  pessary  thus  well  arranged,  acts  precisely  as  a 
splint  in  the  surgical  treatment  of  wounds,  fractures,  etc.;  and,  in 
our  opinion,  is  as  valuable  in  the  one  case  as  in  the  other,  keep- 
ing the  cervix  at  comparative  rest,  and  freeing  it  from  pressure. 

Bearing  the  above  remarks  in  mind,  most  of  the  prejudices 
and  objections  which  have  been  entertained  against  pessaries, 
under  all  circumstances,  and  especially  where  any  inflammation 
exists  about  the  cervix,  will  be  entirely  obviated.  All  those 
forms  of  pessaries,  such  as  the  "  globe,"  the  "ellipse,"  the  "  disc," 
which  necessarily  come  in  contact  with  the  neck  of  the  uterus 
with  more  or  less  force,  are  highly  detrimental.  The  irritations 
also  which  must  necessarily  arise  if  a  pessary  too  large  be  em 
ployed,  will,  of  course,  be  injurious.  In  neither  of  these  cases 
would  the  proper  indications  be  fulfilled  of  supporting  the  uterus 
without  pain  or  irritation,  and  of  isolating  the  cervix  from  all 
pressure  either  from  the  pessary  or  the  surrounding  tissues. 

If  properly  adjusted,  and  of  a  suitable  size  and  form,  it  is  very 
wonderful  how  the  local  and  general  nervous  irritations  are 
diminished,  or  how  the  sensations  of  fulness  and  pressure  are 
dissipated,  while  the  congestion  and  the  leucorrhoeal  discharges  are 
partially  relieved.  The  irritations  kept  up  by  pressure  being  re- 
moved, the  active  and  inflammatory  congestions  are  lessened  and 
consequently  the  disposition  to  resolution  is  greatly  facilitated. 

Another  very  essential  advantage  of  this  treatment  is,  that  rest 
in  the  recumbent  position  is  no  longer  necessary;  the  patient 
may  rise,  walk  about,  and  even  moderately  strain  at  stool  with- 
out exciting  pain  or  aggravating  the  inflammatory  action.  Hence, 
all  the  miserable  consequences  of  confinement  to  close  apart- 
ments, of  impure  air,  increasing  the  dyspeptic  and  nervous  affec- 
tions of  the  patient,  and  still  further  diminishing  her  strength, 
are  obviated.  On  the  contrary,  being  permitted  to  move  about, 
and  attend  upon  her  usual  avocations,  mind  and  body  are  re- 
freshed, and  often  she  can  hardly  realize  that  she  is  indeed  an 
invalid. 

Mild  antiphlogistic  measures  are,  however,  necessary,  and 
under  these  circumstances  will  very  generally  be  efficient  in  caus- 
ing resolution.     Every  one  is  familiar  with  their  use,  yet  some 


160  COMPLICATIONS    OF    IRRITABLE    UTERUS. 

judgment  is  required  in  tlie  cTioice  of  different  remedial  agents. 
Tepid  or  cool  water  freely  injected  into  the  vagina,  at  least  twice 
every  day,  is  all  important.  Astringent  wasbes  also  are  valu- 
able ;  wbere  there  is  much  heat  or  irritation,  nothing  seems  com- 
parable to  a  solution  of  borax  and  morphia.  If  the  inflammation 
has  been  partially  subdued,  solutions  of  alum,  sulphate  of  zinc, 
acetate  of  zinc,  acetate  of  lead,  tannic  acid,  may  be  successively 
emploj^ed.  Sometimes  these  articles  may  be  employed  in  the 
form  of  suppositories,  which  is  a  better  name  than  that  of  "medi- 
cated pessaries."  If  further  remedies  be  required,  solutions  of  the 
sulphate  of  copper,  or  persulphate  of  iron,  will  be  advantageous ; 
and  also  weak  solutions  of  nitrate  of  silver,  which,  with  some 
directions,  can  readily  be  applied  by  the  patient  herself  by  means 
of  a  syringe.  Where  there  is  erosion,  or  a  granular  condition 
of  the  cervical  membrane,  a  solution  of  nitrate  of  silver,  still 
stronger — say  twenty  or  thirty  grains  to  the  ounce — may  be 
applied  by  a  camel's  hair  brush,  through  a  speculum,  directly  to 
the  abraded  surfaces.  More  than  this  is  seldom  requisite.  If, 
however,  the  granulations  be  much  elevated — especially  if  they 
assume  a  fungous  character — the  solid  nitrate  directly  applied 
will  be  very  efficient.  In  our  own  practice  we  have  never  found 
anything  more  to  be  requisite.  Cases  have  sometimes  been 
tedious,  but  still,  under  the  above  treatment,  resolution,  and  the 
return  of  the  tissues  to  their  normal  state,  have  been  effected 
without  any  resort  to  caustics,  actual  or  potential.  The  pessary 
need  seldom  be  removed,  and  should,  indeed,  be  worn  for  months 
and  even  years  to  prevent  cervical  irritation,  which  might  return 
if  the  pressure  from  the  superincumbent  tissues  be  not  obviated. 

By  these  simple  measures,  therefore,  in  perfect  accord  with  the 
treatment  of  chronic  conjunctivitis,  and  of  other  inflammations  of 
mucous  membranes,  these  affections  of  the  cervix  uteri  can  be 
readil}^  managed ;  while,  under  the  genial  influence  of  a  good 
diet,  fresh  air  and  exercise,  the  general  health,  instead  of  being 
deteriorated  by  tedious  confinement,  by  mental  and  physical 
depression,  and  by  painful  and  dangerous  remedies,  begins  imme- 
diately to  improve,  and  is  often  fully  established  before  the  local 
inflammation  has  been  entirel}''  dissipated. 

In  the  treatment  of  endometritis  of  the  body  of  the  uterus  the  same 
general  principles  are  applicable,  especially  as  this  affection  is  so 
often  dependent  upon  local  congestions  or  inflammations  of  the 


TREATMENT    OF    ENDOMETRITIS.  181 

cervix;  these,  therefore,  being  relieved,  the  former  also  subside. 
When  inflammation  of  the  cavity  of  the  body  is  more  localized, 
great  care  should  be  taken  to  avoid  all  sources  of  irritation, 
mental  and  corporeal;  all  ovarian  and  sexual  excitements  are  to 
be  resisted;  all  displacements  of  the  uterus  to  be  removed ;  consti- 
pation to  be  prevented,  and  astringent  washes  to  the  vagina  to  be 
employed.  All  authors  seem  to  acknowledge  their  efficacy  when 
thus  used.  Many  indeed  have  advised  that  such  lotions,  includ- 
ing even  those  of  nitrate  of  silver,  should  be  injected  into  the 
uterus;  and  doubtless  they  would  be  efficient  in  diminishing  the 
inflammation ;  but  the  objections  to  their  use  are  very  positive. 
The  operation  itself  is  painful,  and,  in  most  cases,  the  presence  of 
even  a  few  drops  of  fluid  in  the  uterine  cavity  is  intolerable ; 
neuralgic  and  spasmodic  symptoms,  similar  to  labor,  are  excited. 
Moreover,  Churchill,  Simpson,  West,  and  others — the  best  au- 
thorities in  the  profession — insist  upon  their  being  dangerous 
even  to  the  life  of  the  patient,  as  the  fluid  has  passed,  they  say, 
through  the  Fallopian  tubes  into  the  cavity  of  the  abdomen, 
exciting  acute  and  even  fatal  peritonitis.  The  dangers  are  so 
great  that  any  benefit  they  promise  would  be  entirely  counter- 
balanced; hence  they  should  seldom,  if  ever,  be  employed. 

Bold  practitioners  therefore  propose  to  dilate  the  cervix  uteri, 
and  then  apply  astringent  powders,  ointments,  and  even  caustics, 
to  the  internal  surface  of  the  uterus.  Nothing  but  the  more 
severe  and  protracted  examples  of  chronic  inflammation  of  the 
cavity  can  possibly  justify  such  extreme  measures.  The  degree 
of  irritation  thus  necessarily  excited,  would  greatly  counteract 
the  anticipated  benefit.  Soothing  remedies  will  be  found  more 
efficient. 

Eevulsive  agents  are  of  course  beneficial,  such  as  warm  fomen- 
tations and  poultices ;  stimulating  and  anodyne  liniments ;  the  oc- 
casional application  of  mustard  or  spice  plasters,  or  of  dossils  of 
lint  wet  with  ammonia,  ether,  chloroform,  etc.  Perhaps  more  per- 
manent advantage  may  be  gained  by  the  repeated  application  of 
small  blisters  one-half  to  one  inch  in  diameter.  Our  experience 
however,  is  decidedly  opposed  to  all  revulsives  which  are  so  irri- 
tating or  painful  as  to  disturb  the  nervous  system  of  the  patient ;. 
more  is  gained  by  the  exercise  of  patience. 

The  treatment  of  inflammations  of  the  substance  of  the  uterus — true 
metritis — must  be,  in  the  acute  stages,  entirely  antiphlogistic,  in- 
11 


162  COMPLICATIONS    OF    IRKITABLE    UTERUS. 

eluding  perfect  rest  in  bed.  Wlien  the  disease  is  chronic,  active 
evacuations  should  be  abandoned.  Mild  and  simple  ablutions  to 
the  vagina,  especially  cool  or  even  cold  water,  when  this  does 
not  excite  pain,  will  be  advantageous,  assisted  by  mild  revulsive 
remedies. 

So  long  as  there  is  much  inflammation,  perfect  rest  should  be 
maintained  ;  but  in  the  latter  stages,  the  patient  may  be  allowed 
to  move  about,  if  the  uterus  be  supported  by  a  suitable  vaginal 
pessary,  which  will  prevent  displacement,  and  keep  the  organ 
comparatively  at  rest. 

Tenderness  or  irritability,  which  so  often  remains  after  inflam- 
mation, must  be  managed  as  in  other  cases  of  irritable  organs. 

If  matter  should  be  found  collected  in  the  cavity  of  the  uterus, 
it  will  be  important  to  facilitate  its  exit  through  the  obstructed 
canal  of  the  cervix.  The  mode  of  relief  depends  upon  the  cha- 
racter of  the  obstruction,  which  may,  in  some  cases,  be  overcome 
by  means  of  bougies  or  sounds  passed  into  the  canal.  Should 
this  not  be  sufficient,  the  whole  tube  should  be  dilated  by  sponge- 
tents,  and  eventually,  if  the  stricture  be  impassable,  a  small  trocar 
and  canula  may  be  carried  through  the  stricture  into  the  uterus 
so  as  to  evacuate  the  matter ;  great  care  being  taken  to  prevent 
its  subsequent  contraction.  Sometimes,  however,  there  is  a  proper 
abscess  of  the  uterine  tissue,  not  easily  to  be  distinguished  from 
similar  cavities  in  the  areolar  tissue,  peritoneum,  ovaries,  etc.  All 
these  pelvic  abscesses  greatly  depress  the  patient's  system,  and 
even  hectic  fever  may  ensue.  In  these  cases  the  expectant  treat- 
ment must  be  adopted ;  urgent  symptoms,  both  local  and  general, 
must  be  palliated  by  appropriate  measures,  until  the  abscess  opens 
upon  some  of  the  mucous  tissues.  This  will  afford  great  relief, 
and  sometimes  the  recovery  will  be  rapid ;  but  more  frequently 
new  collections  take  place,  followed  by  successive  discharges,  and 
the  patient  may  be  kept  for  months  in  this  critical,  miserable 
condition.  Usually,  however,  she  recovers  her  good  health  and 
strength. 

In  some  few  cases,  the  indications  of  a  pelvic  abscess  are  so 
decided,  and  the  fluctuation  or  pointing  so  perceptible,  that  the 
practitioner  will  be  justified  in  puncturing  the  abscess  through 
the  vaginal  walls,  thus  insuring  a  free  discharge  and  a  more 
speedy  obliteration  of  the  cavity.  The  difficulty,  however,  of 
establishing  a  clear  diagnosis   between    this   and   other   pelvic 


TREATMENT    OF    INFLAMMATION.  163 

tumors,  sucli  as  hcematocele,  hernia,  ovarian  cysts,  etc.,  is  so  great 
that  much  care  and  tact  are  demanded  to  decide  upon  the  pro- 
priety of  a  puncture. 

The  general  treatment,  in  all  such  cases,  should  be,  of  course, 
strongly  restorative. 

The  treatment  does  not  vary  materially  from  those  of  other 
pelvic  irritations,  so  long  as  there  is  any  decided  symptoms  of 
inflammation  or  fever ;  any  troublesome  local  disturbance  must 
be  obviated.  M.  Berniitz  thinks  that  iodine  may  be  useful  to 
promote  resolution  and  absorption.  If  tumors  are  formed,  the 
patient  should  be  trusted  to  rest  and  the  usual  treatment ;  if  any- 
thing like  fluctuation  be  perceptible,  exploration  by  the  needle 
may  sometimes  be  justifiable ;  if  distinct  fluctuation  and  an  ab- 
scess be  detected,  it  is  best  to  make  a  free  opening  for  the  com- 
plete evacuation  of  the  pus.  Afterwards,  not  much  can  be  done 
excepting  a  daily  resort  to  vaginal  injections.  M.  Berniitz  objects 
very  correctly  to  throwing  fluids,  even  water,  into  the  abscess,  as 
has  been  so  frequently  recommended ;  he  believes  that  iodine  and 
other  kindred  articles  would  be  productive  of  irritation  and  in- 
flammation, and  thus  enhance  greatly  the  dangers  of  the  patient. 
The  general  cachectic  condition  of  the  patient  demands  constant 
and  appropriate  treatment. 

Where  deviations  of  the  uterus  exist,  M.  Berniitz  objects  strongly 
to  the  use  of  pessaries,  which  certainly  are  improper,  while  symp- 
toms of  peritonitis  continue;  but  if  these  have  vanished,  there 
can,  we  think,  be  no  objection  to  the  use  of  pessaries  for  the 
support  of  the  enlarged  and  heavy  uterus,  and  for  obviating  any 
existing  displacement.  They  thus  relieve,  instead  of  increasing 
irritation. 

In  those  chronic  cases  of  retroversion  of  the  uterus,  where  the 
fundus  may  be  fixed  in  its  unnatural  position,  in  consequence  of 
adhesion  to  the  peritoneal  surfaces,  and  where  inflammation  has 
ceased,  we  think  much  advantage  may  be  gained  by  the  pessary ; 
by  careful  manipulation,  the  instrument  can  be  made  to  press  not 
against  but  under  and  behind  the  uterus,  where  the  peritoneal 
adhesions  exist,  and  thus  gradually  to  elongate  the  adhesions, 
and  materially  contribute  to  the  comfort  of  the  patient ;  and  in 
some  chronic  cases  of  supposed  adhesion,  we  have,  by  patient 
perseverance,  restored  the  fundus  to  its  natural  position,  not  only 
without  detriment,  but  with  great  relief.     We  regard  pessaries 


164  COMPLICATIONS    OF    IRRITABLE    UTERUS. 

therefore  as  palliatives  at  least,  in  all  cases  of  retroversion,  with 
peritoneal  adhesions. 

The  nervous  symptoms  are  to  be  moderated,  and  the  tone  of 
the  system  elevated  by  tonics,  diet,  and  constant  resort  to  bath- 
ing, frictions,  exercise,  etc. 

The  treatment  of  hypertrophy  of  the  uterus^  according  to  the  prin- 
ciples which  we  have  inculcated,  is  also  very  simple.  The  most 
common  form  is  hypertrophy  of  the  cervix  uteri.  The  important 
indication  is  to  remove  the  cause  of  the  vascular  congestion,  and 
of  the  consequent  development  or  proliferation  of  the  areolar  or 
muscular  tissues.  Hence,  all  inflammations  of  the  mucous  mem- 
brane are  to  be  subdued — all  pressure  from  scybalous  matters  in 
the  rectum — all  straining  at  stool,  and  especially  all  displace- 
ments of  the  uterus,  which  includes,  therefore,  the  employment 
of  ring  pessaries,  so  as  to  isolate  the  neck  of  the  uterus,  and  free 
it  from  pressure.  Of  course,  also,  all  mental,  sexual,  and  other 
physical  excitements  are  to  be  obviated,  and  great  attention  paid 
to  the  health  of  the  patient.  Tonics  are  almost  always  advanta- 
geous. Many  physicians  still  put  confidence  in  deobstruents 
or  resolvents ;  if  employed,  they  should  not  be  of  an  irritating 
character  or  such  as  would  directly  or  indirectly  impair  the 
general  health  of  the  patient.  A  course  of  mercury,  therefore, 
formerly  so  common,  should  be  entirely  abandoned.  There 
would  be  no  objections  to  the  emploj^ment  of  guaiacum,  sarsa- 
parilla,  and  other  analogous  articles.  Occasionally  the  conium 
maculatum,  formerly  so  much  employed,  the  hyoscyamus  and 
belladonna  may  be  useful  as  palliatives,  and  we  think  that  no 
objection  can  be  advanced  against  the  employment  of  the  iodides 
and  bromides,  as  they  at  least  serve  to  diminish  irritation,  even  if 
they  have  no  decided  eft'ect  in  promoting  absorption.  We  have 
often  used,  therefore,  as  a  tonic  and  alterative,  the  iodide  of  iron, 
while  the  tincture  or  ointment  of  iodine  may  be  applied  to  the 
cervix,  or  by  frictions  to  the  hypogastrium. 

Cool,  cold,  and  astringent  washes  in  all  their  varieties,  per 
vaginam,  are  valuable;  and  occasionally  slight  touches  with  the 
solid  nitrate  of  silver  to  the  os  and  cervix,  seem  beneficial  in  pro- 
moting the  activity  of  the  absorbents.  Further  than  this  we  have 
not  gone,  nor  can  we  go.  We  see  no  justification  whatever  for 
the  application  of  powerful  caustics,  with  all  their  present  incon- 
veniences and  subsequent   dangers  to  a  hypertrophied  cervix, 


GENEEAL    CONCLUSIONS.  165 

witli  the  object  of  stimulating  or  altering  its  vital  actions ;  far 
better  abandon  all  treatment.  Our  experience,  however,  is  in 
favor  of  the  simple  measures  recommended,  especially  with  the 
removal  of  all  pressure  through  the  medium  of  a  pessary,  so  that 
the  irritation  being  obviated,  the  vascular  congestion  gradually 
vanishes,  and  resolution  ensues  by  the  natural  processes. 

The  process  of  resolution  may  doubtless  be  facilitated  by  the 
use  of  tepid  or  cool  water,  a  pint  or  more  being  thrown  into  the 
vagina  twice  or  thrice  in  the  twenty-four  hours;  this  should 
be  followed  by  the  use  of  astringent  washes.  Hence  alum, 
tannic  acid,  acetate  of  lead,  sulphate  of  zinc,  sulphate  of  copper, 
may  all  be  advantageous.  In  very  chronic  cases  stimuli  may 
be  resorted  to — such  as  tincture  of  iodine,  as  already  mentioned ; 
aqua  ammonias,  diluted;  also  solutions  of  nitrate  of  silver,  and 
occasionally  slight  touches  of  the  solid  nitrate  may  be  useful. 

Hypertrophy  of  the  hody  of  the  uterus  should  be  managed  upon 
the  same  principle,  as  it  is  often  the  result  of  endometritis ;  this 
should  be  attended  to  only  in  the  expectation  that  some  benefit 
can  be  secured  from  any  treatment.  All  displacements,  also, 
should  be  rectified,  as  they  are  a  constant  source  of  irritation. 
Let  it  not  be  thought  strange  that  we  should  maintain  the  advan- 
tage of  a  pessary  even  when  no  displacement  is  recognized  in  the 
recumbent  position ;  for  in  cases  of  enlarged  uterus  the  pressure 
from  the  weight  of  the  organ  becomes  distressing  when  the 
patient  is  erect,  and  more  or  less  friction  to  the  os  and  cervix 
will  result,  in  all  attempts  to  walk.  The  cold  douche  internally 
and  externally,  as  well  as  the  internal  and  external  employment 
of  iodine,  is  valuable. 

General  Conclusions. — Our  personal  experience  has  been 
derived  chiefly,  indeed,  from  the  treatment  of  those  in  the  upper 
walks  of  life,  and  in  comfortable  circumstances ;  and  has  been 
comparatively  slight  among  the  poor,  or  in  dispensaries  or  hospi- 
tals, where  local  diseases  doubtless  present  their  worst  aspects, 
and  often  simulate  more  directly,  and  are  more  frequently  com- 
plicated with,  specific  or  malignant  irritation.  Judging  from 
what  we  have  seen,  the  conclusion  seems  to  be  inevitable,  that  the 
great  error  in  the  practice  of  many  is  in  not  drawing  the  proper 
distinction  between  the  varieties  of  uterine  congestion,  between 
those   symptoms   depending   on   nervous   and  those  on  organic 


166  COMPLICATIONS    OF    IRRITABLE    UTERUS. 

irritation,  between  an  irritable  and  an  inflamed  tissue,  in  magni- 
fying the  importance  of  the  latter  and  paying  little  heed  to  the 
former  and  more  common  form  of  uterine  trouble.  Although 
more  common  and  far  more  painful,  yet  it  is  less  dangerous,  very 
seldom  fatal,  and  ultimately  recoveries,  especially  after  the  grand 
climacteric  of  woman's  life,  may  generally  be  anticipated. 

Inflammation,  nevertheless,  is  occasionally  the  cause  of  nervous 
irritation  of  the  uterus  ;  and  in  such  cases,  therefore,  the  latter  will 
entirely  disappear  under  the  antiphlogistic  treatment,  and  the 
recovery  be  complete.  We  believe,  however,  that  in  many 
instances  recovery  will  be  facilitated  by  attention  to  the  more 
purely  nervous  symptoms  ;  that  such  nervous  affections  often 
demand  the  chief  attention  ;  that  in  a  very  large  number  of 
supposed  cases  of  inflammation  they  require  primary  and  exclusive 
treatment ;  and,  finally,  that  it  is  not  unfrequent  that  after  every 
evidence  of  inflammatory  action  has  disappeared  for  weeks,  months, 
or  years,  and  where  phlogosis  had  been  the  original  complaint, 
the  patient's  urgent  and  distressing  affections  continue,  and  are 
often  increased  in  severity  from  a  neglect  or  mismanagement  of 
nervous  irritation. 

These  principles  will  be  more  and  more  developed  in  the 
further  history  of  the  symptoms,  causes,  and  treatment  of  irri- 
table uterus. 


TUMORS  AND  OTHER  COMPLICATIONS. 

Irritable  uterus  may  be  coexistent  with  almost  every  variety 
of  morbid  action,  but  generally  as  a  sequence.  It  follows  and 
accompanies,  therefore,  not  merely  inflammation,  but  tumors 
(extra,  or  intra-uterine),  syphilitic,  phagedenic,  cancerous,  and 
other  morbid  affections,  which  need  not  be  here  detailed. 


GENERAL    SYMPTOMS    OF    IRRITABLE    UTERUS.        167 


CHAPTER    V. 

GENERAL  SYMPTOMS  OF  IRRITABLE  UTERUS. 

Under  the  head  of  the  Local  Symptoms  of  Irritable  Uterus, 
we  have  noticed  all  those  connected  with  the  viscera  of  the  pelvis, 
and  the  adjacent  tissues,  including  the  sacral  nerves. 

Symptoms,  of  course,  are  frequently  excited  in  other  parts  of 
the  body,  which  may  be  denominated  General  Symptoms. 

By  this  expression  is  meant,  in  the  first  place,  and  chiefly,  that 
one  or  more  of  the  general  systems  or  tissues  of  the  body  (the 
cerebro-spinal  nervous  system,  or  the  vascular  system  of  the 
heart,  arteries,  and  veins)  have  become  involved.  This  word 
general  may  be  employed  with  sufficient  accuracy,  when  we  refer 
merely  to  the  nervous,  or  simply  to  the  vascular  apparatus. 

Secondly,  we  would  also  include,  under  the  head  of  General 
Symptoms,  what  may  be  termed  the  sympathetic  or  reflex  dis- 
turbances of  particular  organs  ;  as  such  disturbances  seem  usually 
to  arise  through  the  medium  of  one  or  both  of  these  general 
systems.  By  the  word  reflex^  it  may  be  understood  that  such 
sympathies  are  secondary,  even  when  instantaneously  perceived. 
Pain,  for  example,  excited  in  one  organ,  produces  spinal  or  cere- 
bral irritation,  primarily,  but  secondarily,  yet  often  instantane- 
ously, disturbs  another  organ.  The  irritation  then  is  said  to  be 
reflected  from  or  through  the  brain,  or  spinal  marrow,  to  the 
organ  thus  secondarily  disturbed. 

"Wonderful,  indeed,  is  the  connection  of  one  portion  of  the  body 
with  another ;  one  part  of  the  vascular  system  with  another ;  and 
one  part  of  the  nervous  apparatus  with  every  other  portion  !  The 
animal  economy  becomes  a  unit,  through  the  mutual  dependence 
of  the  nervous  and  vascular  systems  upon  each  other. 

Nevertheless,  much  local  irritation,  especially  of  the  vascular 
system,  may  exist  without  any  perceptible  influence  on  other 
parts ;  and  one  great  object  of  the  author  is,  to  enforce  the  idea, 
that  with  great  dependence  there  is  also  great  independence,  of 


168        GENERAL    SYMPTOMS    OF    IRRITABLE    UTERUS. 

the  nervous  system,  on  the  actions  and  functions  of  organic  life. 
The  animal  life,  as  centred  in  the  brain  and  its  appendages,  has 
its  peculiar  functions,  and  its  peculiar  diseases.  They  are  often 
independent,  but  still,  frequently  involve  the  circulatory  system 
and  its  functions. 

Local  irritations  of  the  nervous  system  affect  other  portions  of 
that  system  much  more  frequently,  and  much  more  severely,  than 
irritations  of  the  vascular  influence  other  portions  of  its  system. 
As  in  woman,  all  her  nervous  system  is  wonderfully  suscep- 
tible ;  so  in  her,  local  irritations  are  propagated  with  such  a  ce- 
lerity and  intensity,  as  to  constitute  physiologically  and  patholo- 
gically, the  great  mental,  moral,  and  physical  characteristics  of 
her  sex.  This  remark  applies  so  positively  to  uterine  irritations, 
that  it  has  been  said,  "  mulier  est  propter  uterum,"  a  woman  is 
what  she  is,  on  account  of  her  uterus.  The  ancients,  close  ob- 
servers as  they  were,  denominated  all  such  sympathetic  disturb- 
ances "  Hysteric,"  from  varifa,  the  Greek  name  given  to  the 
womb. 


CEREBROSPINAL  IRRITATIONS. 

These  general  remarks  being  premised,  we  would  trace  the 
consequences  or  sympathies  of  uterine  irritation.  These,  as  re- 
gards the  cerebro-spinal  system,  from  its  continuity  and  mutual 
dependence,  can,  for  the  most  part,  be  easily  exhibited.  The 
nerves  of  the  uterus,  coming,  as  they  do,  from  the  sacral  plexus, 
but  more  especially  from  the  hypogastric  ganglion  and  plexus, 
and  intimately  connected  with  the  sacral  nerves,  are  traceable  to 
the  Cauda  equina,  the  spinal  marrow,  and  the  brain.  A  j^riori^  we 
should  suppose  that  the  whole  of  this  system  would  be  simulta- 
neously disturbed.  Although  this  is  sometimes  true,  yet  generally 
only  particular  portions  seem  to  suffer  at  one  time.  This  irrita- 
tion often  passes,  in  a  manner  the  most  inexplicable  to  all  our 
present  knowledge  on  the  subject,  from  one  portion  of  the  spinal 
axis  to  another,  or  even  to  different  parts  of  the  brain. 

Spinal  Irritation. — Uterine  pains  are  generally  referred  to 
the  "  small  of  the  back,"  that  is,  to  the  upper  portion  of  the  sacral 
region ;  and  occasionally  to  its  lower  part,  or  to  the  neighborhood 


SPINAL    IRRITATION.  169 

of  the  coccyx.  Very  few,  if  any,  patients  refer  their  sensations 
of  pain  to  the  loins ;  there,  weakness,  in  common  Avith  all  the  mus- 
cles of  the  spine,  is  felt,  but  rarely  pain.  The  next  point  of  refer- 
erice  and  complaint  is  to  the  dorsal  region,  generally  upon  one 
or  the  other  side  of  the  spinal  processes,  and  extending  toward  the 
scapulae.  The  next  most  frequent  point  of  spinal  suffering  is  the 
upper  part  of  the  cervical  region,  under  the  base  of  the  occiput. 

This  pain,  in  the  neighborhood  of  the  spine,  differs  much  in  its 
character,  in  the  same  and  especially  in  different  patients.  When 
in  the  sacral  region,  it  is  generally  a  dull,  heavy,  aching  sensation, 
with  feelings  of  numbness  and  weariness,  and  of  exhaustion. 
They  are  partially  mitigated  by  pressure  from  the  hand,  from  a 
bandage,  or  by  lying  on  the  back,  sometimes  with  a  hard  sub- 
stance, as  a  book,  interposed  between  the  back  and  the  bed. 
Sometimes,  however,  there  is  a  burning  or  even  a  pulsating  pain, 
and  often  great  soreness,  so  that  the  patient  cannot  comfortably 
lie  on  her  back  or  bear  any  pressure  there  without  complaint. 

In  the  dorsal  region,  the  sensation  of  pain  is  frequently  more 
acute,  and  very  often  there  is  considerable  soreness  of  the  skin 
over  the  spinal  processes.  In  the  days  when  the  theory  of  spinal 
irritation  was  so  prevalent,  if  such  spots  were  detected,  particular 
morbid  action,  even  inflammatory,  was  thought  to  be  indicated 
at  that  portion  of  the  spinal  marrow.  A  morbid  irritation  of  the 
medulla  spinalis  was  and  is  even  now  too  frequently  regarded  as 
the  primary  affection,  instead  of  secondary  and  sympathetic. 

Pain  with  or  without  soreness  in  the  cervical  region  varies  also 
exceedingl}'.  Here  it  is  often  aggravated  by  motion,  is  often 
supplanted  by  various  distressing  sensations,  and  sometimes  by  a 
most  annoying  pulsating,  throbbing  feeling,  giving  little  rest 
night  or  day. 

All  these  symptoms  constitute  what  is  usually  termed  "  spinal 
irritation,"  or  "  spinal  affection." 

Cerebral  Irritation. — Evidences  of  cerebral  irritation  are 
also  exceedingly  common.  One  of  the  most  frequent  of  these  is 
pain  or  distress  at  the  top  of  the  head,  near  the  junction  of  the 
fronto-parietal  and  the  bi-parietal  sutures,  in  the  adult,  at  the 
"  opening  of  the  head,"  where  the  anterior  bregma  had  existed,  in 
infancy.  This  pain  is  not  usually  acute,  but  generally  dull,  heavy, 
and  distressing ;  sometimes  it  is  intensely  agonizing,  actually  in- 


170        GENERAL    SYMPTOMS    OF    IRRITABLE    UTERUS. 

tolerable,  being  followed  by  convulsions  and  insensibility  of  a 
longer  or  shorter  duration.  It  is  usually  quite  circumscribed,  and 
can  often  be  covered  by  tlie  point  of  the  finger.  The  ancients 
knew  of  it  under  the  expressive  distinction  of  the  "  clavus  hysteri- 
cus ;"  but  the  moderns  seem  to  have  been  slow  to  recognize  its 
almost  universal  dependence  on  pelvic  irritation.  It  is  hardly  to 
be  met  with  in  the  male  sex,  and  seldom  in  any  woman  free  from 
sacral  or  uterine  irritation.  It  is  often  suddenly  induced,  and  as 
suddenly  relieved,  according  as  the  pelvic  excitement  is  active  or 
passive.  It  seems  to  be  almost  pathognomonic  of  uterine  irrita- 
tion. Pains  somewhat  analogous,  but  less  intense,  are  occasion- 
ally felt  in  other  parts  of  the  head,  especially  towards  the  occipital 
region.  These,  perhaps,  represent  irritations  towards  the  base  of 
the  brain,  in  the  region  of  the  medulla  oblongata,  etc.  In  the 
frontal  region  various  pains  exist.  These  are  chiefly  of  the  neu- 
ralgic character,  severe,  acute,  pulsating,  with  more  or  less  sore- 
ness extending  to  the  adjoining  part,  and  are  known  by  the  name 
of  nervous  headaches  or  cephalalgias. 

There  is  also  every  variety  of  morbid  sensation,  such  as  acute, 
dull,  or  heavy  pains ;  great  soreness  of  the  scalp  ;  feelings  of  mo- 
tion as  if  the  bones  were  opening  and  shutting ;  or  the  head  feels 
too  empty  or  full,  as  if  it  were  swollen,  or  enormously  enlarged. 
These,  and  innumerable  other  sensations,  are  all  indicative  of 
irritation  of  the  brain  dependent  very  frequently  on  pelvic  dis- 
turbance. They  are  examples  also  of  morbid  sensations  which 
are  actual,  real,  and  not  imaginary,  the  result  of  morbid  excite- 
ment, though  frequently  transitory  and  free  from  danger. 

Generally,  these  are  the  evidences  of  spinal  and  cerebral  irrita- 
tion from  uterine  affections.  But  often  the  head  entirely  escapes, 
not  unfrequently  the  neck,  and  occasionally  the  dorsal  region. 
In  some  instances  the  dorsal  pain  is  experienced,  when  no  uneasi- 
ness exists  in  the  sacrum,  or  in  the  head,  and  when  the  spine  is 
comparatively  free.  Most  frequently,  patients  are  conscious  of  a 
succession  of  pain  from  the  sacrum  to  the  head ;  sometimes  as 
one  begins  the  other  vanishes.  The  uterine  irritations  in  some 
few  cases  is  referred  to  the  hypogastric  region,  and  the  sacral  re- 
mains unaffected.  Perhaps  in  such  cases  there  is  less  general 
nervous  disturbance. 

These  pains  and  morbid  feelings,  as  experience  proves,  are 
dependent  on  the  condition  of  the  uterus ;    when  this  organ  is 


LANGUOR.  171 

relieved  they  disappear,  when  the  womb  is  disturbed  they  ap- 
pear in  a  greater  or  less  degree,  with  a  celerity  of  transition  often 
wonderful.  They  indicate  spinal  and  cerebral  irritation,  that  is, 
irritation  of  the  spinal  marrow  and  of  the  cerebral  mass  (cerebrum 
and  cerebellum),  as  the  centres  or  source  of  nervous  influences, 
not  as  the  subjects  of  organic  life.  It  is  nervous,  not  organic , 
animal,  not  vegetable  life ;  and  has  reference  to  the  disturbance 
of  the  nervous  system,  and  not  of  the  blood. 

/  Langltoe. — One  of  the  most  common  of  these  general  symp- 
toms in  uterine  affection  is  "  weakness,"  so  called  by  the  patient, 
but  better  expressed  by  the  words  languor,  lassitude,  inertness, 
or  by  the  French  word  "defaillance."  There  is  a  general  sense 
of  prostration,  as  if  it  were  impossible  to  make  any  exertion. 
Sometimes  this  is  the  case,  when  the  local  symptoms  are  by  no 
means  urgent,  often  when  there  is  but  little  pain  ;  and  in  a  few 
cases  where  no  pain  whatever  had  been  experienced,  even  as  we 
have  known,  after  some  twelve  or  fifteen  years  of  this  disability. 
Under  the  stimulus  of  a  strong  will,  of  great  mental  or  moral 
excitement,  or  even  of  physical  stimuli,  such  patients  can  make 
temporary  exertions ;  but  will  afterwards  relapse,  usually  into  a 
more  decided  state  than  ever  of  apparent  exhaustion. 

To  these  sufferers,  the  only  comfortable  position  is  the  recum- 
bent ;  it  is  an  effort  to  sit,  stand,  or  walk.  In  onr  -lase  which  had 
continued  for  some  twelve  years,  walking  could  not  be  attempted, 
and  for  eight  months  the  patient  had  been  unable  to  make  an 
effort  even  to  feed  herself;  yet  she  had  no  urgent  local  symptoms, 
and  no  pain.  In  some,  the  same  lassitude  affects  the  mind  and 
feelings  of  the  patient ;  no  interest  is  expressed  in  the  usual  social 
relations  and  business  of  life.  To  the  patient  all  things  are  indif- 
ferent, and  most  objects  of  affection  decidedly  wearisome  and  per- 
turbing. In  most,  however,  there  is  considerable  local  irritation, 
as  evinced  by  pain  in  the  back,  a  sense  of  pressure,  etc. 

In  many  of  these  cases  of  general  languor,  the  patient  is  appa- 
rently well,  and  has  a  good  appetite,  digestion,  circulation,  and 
nutrition.  Hence,  they  usually  become  the  objects  of  unchari- 
table criticism,  under  the  idea  that  a  will  alone  is  wanting  to  dis- 
sipate all  their  ailments.  In  very  many,  however,  there  is  more 
or  less  pallor,  some  emaciation,  conjoined  with  dyspeptic  symp- 
toms, and  costive  bowels.     Professionally,  such  individuals  are 


172       GENERAL    SYMPTOMS    OF    IRRITABLE    UTERUS. 

often  regarded  as  anaemic  or  dyspeptic,  and  are  treated  merely  by 
tonics,  nutritious  diet,  exercise,  etc.  But  usually  in  vain,  for  the 
symptoms  of  angemia  and  dyspepsia  are  the  results  of,  perhaps, 
the  confinement  with  its  concomitant  evils,  and  not  the  original 
source  of  mischief,  which  remains  unnoticed.  This  feeling  of 
muscular  languor  or  debility  is  generally  connected  with  much 
pelvic  distress,  often  with  positive  pain  and  the  other  local  symp- 
toms already  mentioned. 

Irritations  along  Particular  Nerves. — These  distressing 
sensations  are  felt  not  only  in  the  back,  hips,  and  in  the  lower 
part  of  the  iliac  regions,  but  radiate  in  every  direction  from  the 
source  of  mischief  in  the  pelvis.  Occasionally  they  may  be 
traced  from  the  groin  in  the  course  of  the  anterior  crural  nerve, 
and  are  often  associated  with  much  soreness,  which  has  been  con- 
founded with  phlebitis ;  more  frequently  they  follow  the  course 
of  the  obturator  nerve  on  the  inside  of  the  thigh,  but  still  oftener 
involve  the  trunk  and  the  ramifications  of  the  great  sciatic  nerve. 
Pain  is  felt  in  the  thighs,  in  the  "  bones,"  the  patient  says,  in  the 
knees,  ankles,  and  often  in  spots,  as  at  the  top  of  the  instep,  or  at 
the  heel,  which  can  often  be  covered,  even  when  severe,  by  the 
point  of  a  finger.  Sensations  of  numbness,  "  a  dead  feeling,"  a 
prickling,  stiffness,  cramp,  as  well  as  weakness  often  coexist,  in- 
creasing the  indisposition  or  inability  to  move.  Very  often  in 
young  girls  such  uneasy  sensations  are  slightly  dismissed  as 
"  growing  pains,"  and,  if  severe,  are  treated  as  rheumatic,  even 
for  long  periods.  Many  such  patients  have  fallen  under  our  care, 
who  for  several  years  had  been  regarded  and  treated  as  confirmed 
rheumatic  cases,  had  proved  intractable  to  the  physician,  a,nd  had 
not  been  relieved  by  resorting  to  travelling,  and  to  warm,  chaly- 
beate, and  sulphur  springs. 

,      Tracing  the  irritation  upwards  towards  the  spinal  marrow,  we 
'  find  neuralgic  pains  in  the  iliac,  lumbar,  and  hypochondriac  re-  • 

\  gions.  The  pain  in  the  right  hypochondrium,  in  conjunction 
with  a  similar  pain  in  the  right  shoulder,  has  been,  in  innumerable 
cases,  regarded  by  patients  and  their  physicians  as  the  sure  evi- 

I  dence  of  "  liver  disease."  "We  have  had  very  many  of  these  pa- 
tients, who  for  years  had  been  subjected  to  the  whole  course  of 
evacuant  and  alterative  treatment  for  chronic  hepatitis.  In  some 
there  had  been  a  free  use  of  mercury,  occasionally,  even  to  saliva- 


IRRITATIONS    ALONG    PARTICULAR    NERVES.  173 

tion  ;  when  the  result  of  subsequent  treatment  proved  that  it  was 
not  hepatic,  but  uterine ;  not  vascular,  but  nervous  irritation. 

Case. — In  one  unfortunate  case,  we  remember,  this  treatment  i 
had  been  adopted  in  a  young  lady  at  the  age  of  eighteen,  and  was  ( 
persevered  in,  at  intervals,  until  she  was  thirty.     Death  occurred 
when  she  was  thirty-two  years  of  age ;  and  a  post-mortem  exami- 
nation revealed   merely  a  fibrous  tumor,  some  three  inches  or  • 
more  in  diameter,  on  the  anterior  portion  of  the  uterus.     The 
liver  was  perfectly  normal,  as  regarded  its  size,  color,  consistence, 
and  texture. 

tSimilar  neuralgic  pains  are  common  in  the  left  hypochondrium, 
but  sometimes  extend  from  the  region  of  the  scapulae  to  the  margin 
of  the  ribsj  to  the  sternum  and  pectoral  muscles,  and  are  often 
associated  with  much  soreness  and  sometimes  spasm.  This  pain, 
in  the  left  side,  has  been  attributed  often  to  gastric  affections,  or 
to  diseases  of  the  heart,  thus  giving  rise  to  much  perturbation  of 
feeling  and  anxiety  of  mind  on  the  part  of  the  patient. 

From  the  upper  portions  of  the  spinal  marrow,  especially  in 
the  region  of  the  upper  cervical  vertebrge,  the  same  kind  of  pains 
radiate  to  the  occipital  region,  to  the  sides  of  the  neck,  and  often, 
in  the  direction  of  the  brachial  plexus  and  nerves,  to  the  tissues 
of  the  upper  extremities.  Here,  as  in  the  inferior  extremities, 
particular  nerves  suffer :  hence,  pain  in  spots  in  the  course  of 
small  twigs  of  the  nerves,  among  the  tissues,  or  along  the  muscles, 
neuralgic  pains  in  the  fingers,  wrists,  elbows,  in  the  upper  arm, 
and  feelings  of  numbness,  deadness,  are  often  felt  with  various 
morbid  distressing  feelings,  not  susceptible  of  description.  These 
pains,  conjoined  with  those  in  the  region  of  the  heart,  have  often 
been  regarded  as  belonging  to  "  angina  pectoris,"  and  considered 
by  many  as  gouty,  by  others  as  dyspeptic,  and  by  some  as  always 
connected  with  diseases  of  the  heart. 

Mypersesthesia  of  the  Skin. — Neuralgic  suffering  is  often  mani- 
fested by  great  soreness  of  the  skin,  so  that  the  least  touch  or 
pressure  is  often  intolerable.  When  the  skin  of  the  abdomen  is 
involved,  this  soreness  gives  rise  to  the  suspicion  of  peritonitis ; 
and  when  it  is  over  the  hypochondria,  to  inflammatory  affections 
of  the  liver,  stomach,  or  spleen.'  When  over  the  chest,  diseases 
of  the  heart  are  often  suspected.  When  in  the  extremities,  it 
confirms  the  ideas  of  rheumatism  and  gout.  Such  soreness  of  the 
cutaneous  tissue  over  the  spinal  column  has  given  origin,  too  fre- 


174        GENERAL    SYMPTOMS    OF    lEEITABLE    UTERUS. 

quently,  to  ideas  of  vascular  engorgements  and  inflammations  of 
the  spinal  cord  and  its  membranes  at  these  spots. 

!  Symptoms  vary,  and  may  be  confined  to  one  side  of  the 
Body. — Such  are  the  usual  consequences  of  spinal  irritation, 
when  the  brain  has  escaped,  or  has  been  but  slightly  involved. 
Sometimes  the  symptoms  are  very  moderate,  so  that  patients  go 
about  their  usual  avocations,  complaining  only  after  unusual  ex- 
citements, or  fatiguing  muscular  efforts;  while  in  others  they  are 
so  severe  that  standing  or  walking  is  intolerable,  and  even  turn- 
ing in  bed  is  painful,  and  much  suS'ering  is  experienced  when 
perfectly  at  rest  on  the  couch  or  bed.  It  is  a  singular  fact,  and 
perhaps  not  fully  to  be  explained,  that  in  almost  all  these  cases 
the  suffering  is  chiefly  upon  one  side  of  the  body,  the  right  or  the 
left.  Patients  have  often  observed,  that  if  the  left  or  the  right 
side  were  as  well  as  the  opposite,  they  would  make  no  complaints. 
The  uterus  being  a  single  organ,  its  nerves  associated  with  each 
sacral  and  sciatic  plexus,  and  no  special  irritation  of  one  set  of 
sacral  nerves  being  traceable,  this  limitation  to  one  side  would 
not,  a  priori^  have  been  expected. 

Cerebral  Disturbances. — Several  of  the  peculiar  symptoms 
of  irritation  of  the  brain  have  been  alluded  to ;  but  now  the  con- 
sequences of  the  disturbance  of  the  cerebral  mass  must  be  traced 
more  distinctly. 

Inasmuch  as  the  brain  is  the  great  centre  and  source  of  nervous 
influence,  it  is  the  instrument,  the  organ  of  the  mental  and  spiritual 
being  through  which  the  body  disturbs  the  spirit,  and  by  which 
all  spiritual  and  intellectual  influences  are  exerted  over  the  animal 
economy. 

•  Cephalalgia  is  one  of  its  most  common  manifestations.  Violent 
^^ain  may  exist  in  the  forehead,  but  more  frequently  in  one  temple, 
extending,  in  the  form  of  severe  neuralgia,  to  the  eyeballs,  the- 
scalp,  the  face,  the  ear,  etc. ;  and  is  often  conjoined  with  great  men- 
tal disturbance  and  apprehension,  and  many  morbid  sensations. 
They  are  often  so  severe,  that  patients  term  them  "  crazy"  head- 
aches ;  and  a  nervous  delirium  is  not  unfrequently  added.  The 
sensibility  of  the  nervous  system  is  painfully  augmented,  so  that 
ordinary  impressions  on  the  senses  become  excessively  intense ; 
the  least  noise,  especially,  vibrates  distressingly  on  the  nerves  and 


r 


DISTURBANCES    OF    THE    BRAIN.  175 

"brain.  These  headaches  endure  for  a  few  hours,  or  may  last  for 
a  day  or  two  ;  and  frequently  are  terminated  by  a  critical  excre- 
tion from  the  kidneys,  in  the  form  of  immense  quantities  of  color- 
less urine — "  diabetes  serosa.']'  (^Often  similar  headaches  are  at- 
tended with  nausea,  vomiting  of  the  food,  of  acid,  or  of  bilious 
matters,  from  the  stomach — the  so-called  "sick  headaches,"  "bil- 
ious headaches" — so  that  the  bile  is  regarded  as  the  source  of  evil.^ 
These  headaches  are  occasionally  very  moderate,  and  are  often 
accompanied  by  feelings  of  great  tension  or  fulness  ;  by  pulsating 
sensations ;  by  the  idea  that  the  bones  of  the  head  are  movable, 
overlapping  each  other ;  by  the  apprehension  of  serious  disease 
of  the  brain  and  of  the  mind. 

These  cephalalgias  are  often  periodical — once  every  month — 
preceding,  during,  or  after  the  menses,  sometimes  both  before  and 
after  the  flow.  Occasionally  they  occur  once  or  twice  a  week,  and 
some  sufferers  can  hardly  say  that  they  are  ever  free  from  pain 
or  morbid  sensation  in  the  head. 

The  "  clavus  hystericus" — the  circumscribed  dull  pain  at  the 
top  or  "  opening  of  the  head" — is  not,  perhaps,  so  frequent ;  but 
is  quite  common  and  persistent,  and  occasionally  connected  with 
the  most  frightful  disturbances  of  the  economy.  In  addition  to 
this  pain  in  the  top  of  the  head,  patients,  in  many  instances,  com- 
plain of  a  dull,  heavy,  stupid  headache,  often  with  a  sense  of 
weight  and  uneasiness  in  the  occipital  region ;  sometimes  there 
are  tinnitus  aurium,  flashes  of  light  from  the  eyes,  and  frequently, 
in  bad  cases,  imperfect  vision. ' 

Convulsions. — These  symptoms  are  often  followed  by  the  most 
aggravated  form  of  convulsions,  as  if  the  pain  and  distress  were 
no  longer  tolerable.  The  muscles  of  the  whole  body,  as  well  as 
those  of  the  face  and  extremities,  become  violently  agitated.  Opis- 
thotonos not  unfrequently  is  seen,  the  head  being  thrown  back  to 
wards  the  spine,  the  feet  drawn  up  under  the  body,  so  that  a  com- 
plete arch,  or  almost  a  circle,  is  made.  In  some  of  such  cases  the 
patient  maintains  her  consciousness ;  in  others  there  is  complete 
insensibility. 

Catalepsy  sometimes  arises  under  these  circumstances,  and  may 
continue,  with  variations,  for  days. 

Deliriura. — Nervous  or  hysterical  delirium  is  observed  in  other 
cases,  either  transitory,  or,  it  may  be,  lasting  for  days.  The 
patient's  mind  is  not  always  in  distress,  but  often  very  pleasantly 


176       GENERAL    SYMPTOMS    OF    IRRITABLE    UTERUS. 

T  excited,  as  if  in  some  gay  or  fancy  land — dreaming,  as  it  were, 
with  some  apparent  knowledge  of  persons  and  things,  but  all 
moving  and  acting  as  if  in  another  sphere.  Mania  is,  probably, 
'  not  unfrequently  the  result  of  uterine  irritation,  (pne  form  of 
this  is  well  known,  under  the  name  of  nymphomania^  But  there 
are  other  cases,  where  there  is  no  apparent  development  of  sexual 
excitement.  The  most  decided  mania,  coming  on,  it  may  be,  in 
paroxysms,  and  enduring  year  after  year,  will  often  alternate 
with  convulsions,  or  exist  without  these  spasmodic  affections. 

Sudden  loss  of  consciousness  and  of  muscular  power  is  occasionally 
observed.  A  patient,  while  standing  or  walking,  may  suddenly 
fall,  and  for  some  time  can  give  no  sign  of  mental  or  motive 
power.  This  is  probably  a  variety  of  the  so-called  cataleptic 
state.     Occasionally  there  is  simulative  apoplexy  and  paralysis. 

Case. — In  a  lady,  the  wife  of  a  physician,  an  attack  of  this  kind 
came  on  suddenly  in  the  night.  A  neighboring  friend  and  sur- 
geon was  sent  for,  who  wisely  forbore  using  any  evacuating 
remedies;  although  the  patient  was  stupid,  and  unable  to  move 
one-half  of  the  body.  The  muscles  of  the  neck,  on  one  side, 
were  also  somewhat  contracted.  In  a  few  days  these  symptoms 
entirely  disappeared. 

•  Intellectual  and  Moral  Distiirhances. — Such  are  some  of  the  more 
important  indications  of  cerebral  irritation,  so  far  as  simple  sensa- 
tion or  pain  is  concerned ;  but  the  brain  is  the  agent  of  the  mental 
and  spiritual  being.  It  is  the  organ  of  the  soul.  In  all  its  irri- 
tations, therefore,  some  disturbance  of  the  intellectual  and  moral 
faculties  may  be  expected.  The  instrument  is  out  of  tune;  so 
that  discordant  notes  will  issue  from  individuals  whose  minds  and 
hearts  are  in  reality  excellent.  Such  intellectual  and  moral  de- 
rangements are  exceedingly  common  in  all  nervous  diseases, 
and  are  much  diversified,  varying  from  the  slightest  mental  dis- 
tress to  the  most  profound  melancholy  or  the  most  vehement  and 
active  forms  of  mania. 

Allusion  has  already  been  made  to  some  of  these  mental  aber- 
rations ;  but  as  they  often  arise  when  there  are  but  few  j^hysical 
disturbances,  and  sometimes  seem  to  constitute  the  disease,  or  the 
most  prominent  evidence  of  a  morbid  state,  we  must  dwell  on 
them  more  at  length. 

Perhaps  the  most  common  disturbance  is  depression  of  the  mind. 
The  patient  is  "  low-spirited,"  is  desponding,  loses  her  interest  in 


HALLUCINATIONS.  lit 

the  common  business  of  life,  performs  her  duties  with  an  effort, 
and  finds  that  it  requires  an  exertion  to  turn  her  thoughts  away 
from  herself.  Gradually  she  loses  her  interest  in  her  friends  and 
in  society,  preferring  solitude  as  more  congenial  to  the  state  of  her 
mind  and  heart.  This  state  often  becomes  very  distressing ;  no- 
thing withdraws  the  patient  from  her  own  morbid  sensations;  she 
is  desponding,  melancholy,  prefers  death  to  life,  and  even  medi- 
tates seriously  as  to  the  value  of  life  under  such  circumstances; 
for,  to  her,  the  future  promises  to  be  like  the  past.  She  expects, 
perhaps  even  desires,  nothing  better;  and  is  almost  ready,  in  her 
despair  of  comfort  here,  to  rush  upon  the  untried  realities 
of  another  world.  These  extreme  cases  are  comparatively  rare, 
but  minor  cases  of  mental  indifference  or  despondency  are  exceed- 
ingly frequent.  On  recovery,  such  patients  often  say,  "a  cloud 
has  been  removed  from  my  mind,"  a  "  load  taken  from  my 
heart,"  "my  head  is  cleared,"  "the  confusion  of  thoughts  has 
vanished,"  "  ray  natural  interest  in  my  husband,  my  children, 
my  duties,  has  returned,"  etc. 

We  have  met  with  many  patients  whose  moral  feelings  might  be 
regarded  as  in  a  state  of  irritation ;  everything  worried  and  agi- 
tated them  ;  the  merest  trifle  not  only  annoyed  but  excited  strong 
expressions  of  displeasure,  and  even  of  anger.  Such  persons 
may  have  sufiicient  self-restraint  to  command  themselves  among 
strangers ;  but  at  home,  among  children  and  domestics,  and  even 
towards  husbands,  self-command  seems  to  be  impossible,  or  at 
least  requires  a  powerful  exercise  of  the  will. 

Cases. — One  lady,  well  educated,  refined,  and  cultivated,  said 
that  she  wondered  how  her  husband  could  endure  her  presence 
in  the  house,  although  before  her  sickness  she  had  always  been 
very  amiable. 

Another  lady,  after  we  had  comforted  her  by  saying  that  the 
disturbance  of  her  passions  was  physical  and  not  moral,  begged 
us  to  inform  her  husband  that  all  her  bad  temper  depended  on  her 
physical  state ;  "  for  indeed,  doctor,"  she  said,  "  I  was  always 
amiable  before  I  suffered  in  this  way." 

These  states  of  mental  and  moral  excitement,  sometimes  even 
in  strong-minded  and  religious  women,  become  uncontrollable 
even  by  the  most  determined  efforts  of  the  will  and  of  the  con- 
science. These  patients  are  really  "  non  compos  mentis ;"  they 
12 


178        GENERAL    SYMPTOMS    OF    IRRITABLE    UTERUS. 

mourn  over  and  are  distressed  and  mortified  at  the  ebullitions  of 
passions  which  they  cannot  restrain. 

Indescribable  and  inexplicable  feelings  of  dread,  anticipations 
of  impending  evil  to  themselves  or  their  friends,  take  possession  of 
the  minds  of  other  patients.  They  fear  to  be  alone,  even  for  an 
instant';  they  cannot  divert  their  thoughts  from  disagreeable  or 
painful  subjects.  They  often  not  only  lose  their  interest  in  their 
relations,  and  are  disposed  to  quarrel  with  them,  but  even  to 
seriously  injure  them. 

Case. — A  lady,  apparently  sane  upon  other  subjects,  but  very 
nervous  and  desponding,  assured  the  author  that  she  would  not 
trust  herself  with  her  own  children ;  she  was  persuaded  she  would 
destroy  them. 

A  variety  of  this  state  of  the  cerebral  functions,  but  usually  not 
so  terrific,  consists  in  hallucinations  and  spectral  illusions  of  various 
kinds.  Every  one  has  heard  of  the  fancies,  the  notions,  the  vaga- 
ries, the  strange  thoughts  and  imaginings  of  nervous  people. 
They  are  sometimes  pleasant,  but  often  very  disagreeable,  and 
ev.en  fearful  to  themselves  or  companions.  In  other  cases,  mental 
hallucinations,  deceptive  perceptions,  are  so  vivid  that  they  appear 
to  be  realities. 

Cases. — A  highly  educated  lady,  of  natural  robust  constitution, 
became  a  great  sufferer  from  bodily  debility  and  mental  troubles, 
yet  maintained  perfect  sanity  and  great  power  over  her  will. 
Sleep  was  often  a  stranger  to  her  system ;  and,  during  the  tedious 
night  watches,  various  forms  and  diversified  sights  would  flit  be- 
fore and  around  her.  One  night  a  young  woman,  who,  she  knew, 
had  been  dead  for  some  months,  was  distinctly  observed  entering 
her  chamber,  walking  about,  and,  finally,  seating  herself.  The 
patient  declared:  "I  knew  it  was  an  hallucination;  I  endeavored 
to  reason  upon  the  absurdity  of  believing  in  the  apparition,  but 
all  in  vain ;  there  sat  the  woman  perfectly  distinct  before  ray  eyes, 
and  did  not  vanish  till  I  arose  from  bed  and  lighted  the  gas." 
-  We  were  requested,  lately,  to  visit  a  lady  from  Virginia  at  one 
of  the  hotels.  We  found  her  a  martyr  to  nervous  affections ;  her 
body  and  mind  seemed  quite  dilapidated.  She  was  a  woman  of 
delicacy,  refinement,  and  spirituality ;  and  was  too  feeble  and 
diseased  to  walk,  or  even  to  sit  up  with  comfort.  It  was  an  effort 
to  her  even  to  converse.  After  several  questions,  we  ventured 
to  ask  her  as  to  the  state  of  her  mind.     No  answer  was  given, 


HALLUCINATIONS.  179 

but  her  tears  immediately  began  to  flow,  so  the  subject  was  waived. 
After  a  few  days,  when  her  symptoms  had  improved,  she  ac- 
knowledged that  her  mind  was  not  only  greatly  confused,  but  in 
a  very  distressed  condition ;  and  whenever  she  was  in  unusual  pain, 
as  at  her  catamenial  periods,  or  agitated  from  any  cause,  she  could 
not  sleep,  and  was  tormented  with  distinct  spectra.  "  People 
would  appear  in  my  room  all  night.  I  could  not  divert  my  at- 
tention from  them.  I  could  see  them  as  distinctly  as  I  see  you, 
and  they  would  continually  talk  to  me,  and  generally  upon  dis- 
agreeable subjects.^ 

In  both  these  cases  all  the  hallucinations  quickly  vanished  upon 
relieving  the  nervous  irritation  of  the  uterus. 

The  wretched  physical  and  mental  sensations  from  cerebral 
disturbance  cannot  be  described.  The  patients  have  no  language 
to  express  the  nature  of  their  feelings,  but  portray  in  strong  and 
eloquent  terms  the  misery,  often  the  horrors,  of  the  mental  and 
spiritual  state  as  far  more  distressing  than  physical  pain. 

The  line  of  demarcation  between  sanity  awl  insanity  cannot 
indeed  be  drawn  in  the  various  states  of  cerebral  disturbance. 
Decided  mania  occasionally  ensues ;  the  patient  sometimes  sinks 
into  the  hopeless  wretchedness  of  melancholy,  or  the  chaotic  mus- 
ings of  idiocy.  These  extremes  are,  however,  rare ;  but,  nothing 
is  more  frequent  than  some  mental  or  moral  disturbance,  depend- 
ent on  uterine  irritation.  When  this  irritation  is  relieved,  the 
cloud  is  removed  from  the  mental  vision ;  the  chaotic  confusion 
of  the  ideas  vanishes  ;  the  indifference  to  friends  and  to  the  busi- 
ness of  life  is  superseded  by  warm  affections  and  active  devotion 
to  duty.  The  morbid  excitements  of  the  mind  subside ;  cheer- 
fulness and  hilarity  succeed ;  the  patient  feels  rejuvenated,  revo- 
lutionized, and  can  hardly  believe  the  reality  of  past  sufferings, 
or  that  she  has  retained  her  personal  identity.) 


180      EEFLEX    INFLUENCES    OF    IRRITABLE    UTERUS. 


CHAPTER   VI. 

GENERAL  SYMPTOMS  OF  IRRITABLE  U  TER  U  S— Continued. 
REFLEX  INFLUENCES  OF  CEREBRAL  AND  SPINAL  IRRI- 
TATION. 

Let  the  well-educated  medical  student  refer  once  more  to  all 
that  he  has  learned  of  the  anatomy  of  the  brain  and  its  depend- 
encies ;  let  him  re-examine  the  best  physiological  investigations 
as  to  the  dependence  and  independence  of  the  nervous  system, 
and  its  connection  with  the  various  actions  and  functions  of  the 
tissues,  organs,  and  apparatuses  of  the  economy.  Then,  calling 
to  mind  the  most  inscrutable,  but  most  intimate  affiliation  of  mind 
and  body,  of  the  spiritual  and  corporeal  nature  of  man,  let  him 
study  all  that  mental  and  moral  philosophers,  all  that  phrenolo- 
gists, metaphysicians,  and  transcendentalists  have  discovered  or 
imagined,  as  to  the  operations  of  the  immaterial  portion  of  oar 
nature ;  yea,  let  him  receive  reverently,  and  as  minutely  as  pos- 
sible, what  is  revealed  in  the  Bible  on  these  mysterious  subjects; 
and  then,  after  the  most  persevering  and  laborious  investigation, 
he  may  form  an  idea  of  the  direct  and  reflex  influences  of  cerebral 
and  spinal  irritation,  whether  from  physical  or  moral  causes,  on 
the  various  portions  of  the  animal  economy.  Daily  experience, 
in  the  treatment  of  such  cases  would  still  further  enlarge  his 
views  ;  and  his  admiration  would  be  excited,  while  contemplating 
the  inexplicable  manifestations  of  nervous  irritation  in  every  part 
of  the  body,  the  mysterious  character  of  organic  and  animal  life, 
and  the  still  more  mysterious  union  and  dependence  between  the 
spiritual  and  corporeal  being.  He  will,  indeed,  be  made  to  feel 
the  limited  character  of  his  knowledge,  and  to  exclaim — How 
wonderful  is  the  constitution  of  man ! 

In  women,  all  these  manifestations  of  cerebral  and  spinal  affec- 
tion are  known  among  systematic  writers  by  the  term  Hysteria ; 
the  phenomena  of  which  are  ever  varying  and  constantly  simu- 
lating more  serious  and  dangerous  diseases.     It  is  said,  therefore, 


SYMPATHY    AND    REFLEX    ACTION,  181 

to  be  "  Proteus-like,"  Its  various  phases,  always  changing  and 
assuming  every  form  of  morbid  action,  too  frequently  lead  even 
the  experienced  practitioner  far  astray  from  the  proper  course  of 
therapeutical  treatment.  Yet  all  these  cases  of  hysteria  are  still 
regarded  by  many  individuals  as  not  real  but  imaginary ;  not 
depending  upon  physical  but  upon  mental  or  moral  causes  ;  not  to 
be  subdued  so  much  by  proper  therapeutical  measures  as  by 
powerful  appeals  to  the  moral  being.  In  many  cases,  the  influ- 
ence of  authority,  or  the  force  of  circumstances  will  give  relief. 


SYMPATHY  AND  REFLEX  ACTION. 

The  cerebro-spinal  nervous  system  (the  centre  of  perception 
and  the  originator  of  sensation  and  motion)  has  a  wonderful  di- 
rect and  indirect  influence  over  all  the  tissues,  organs,  and  func- 
tions. The  character  and  degree  of  such  influence  have  not  yet 
been  fully  elucidated  by  the  anatomist  and  physiologist.  Much 
has  been  done ;  but  much  remains  to  be  done.  Hence,  in  morbid 
derangements  of  organs,  it  is  difficult,  often  impossible,  to  say, 
how  much  results  from  the  direct  influence  of  the  brain  or  spinal 
marrow,  how  much  from  indirect  agency,  and  how  much  may 
ensue  through  a  more  immediate  synergy  or  sympathy  between 
one  or  more  organs  without  any  intervention  of  the  spinal  mar- 
row or  the  brain. 

For  example,  irritations  of  the  stomach  will  disturb  the  brain, 
sometimes  the  liver,  the  heart,  and  the  lungs,  etc. :  so,  also,  the 
irritations  of  the  brain  will  disturb  the  stomach,  liver,  heart,  and 
lungs,  thus  showing  the  intimate  connection  between  the  brain 
and  these  organs.  This,  no  doubt,  is  due  to  the  pneumogastric 
nerve,  passing,  as  it  does,  to  all  these  organs,  from  the  medulla 
oblongata.  The  inference,  however,  is  by  no  means  clear,  that 
there  may  not  be  a  disturbance  of  the  heart,  liver,  or  lungs,  with 
the  stomach,  without  the  intervention  of  the  brain,  or  its  pro- 
longations. Every  one  is  familiar  with  facts  showing  the  sympa- 
thetic connection  of  organs,  as  the  uterus  with  the  stomach,  with 
the  mammae,  etc.  Are  this  and  other  sympathies  effected  by  means 
of  a  direct  influence  of  one  organ  on  another,  or  must  we  travel 
always  along  the  course  of  a  nerve  to  the  spinal  marrow  or  brain, 
and  back  to  the  suffering  organ  ?    Much  has  been,  and  may  easily 


182       EEFLEX    INFLUENCES    OF    IRRITABLE    UTERUS. 

be  adduced  on  botli  sides  of  these  interesting  questions ;  we,  how- 
ever, must  leave  them,  until  further  observations  and  experiments 
have  elucidated  these  arcana.  The  probability  is,  that  there  is 
truth  in  both  statements ;  that  sympathy  is  generally  dependent 
on  the  intervention  of  the  brain  and  medulla  oblongata  et  spinalis, 
and  sometimes,  perhaps,  on  the  ganglionic  nervous  system.  To 
systematize  our  history,  we  will  presume  that  in  nervous  irrita- 
tions, the  impression  is  usually  propagated  through  the  medium 
of  the  cerebro-spinal  centres. 


EXTERNAL   ORGANS. 

Many  of  the  secondary  or  reflex  influences  of  spinal  and  cere- 
bral irritations  have  already  been  noticed,  especially  the  soreness, 
the  pain,  the  spasms,  the  cramps,  and  various  neuralgic  disturb- 
ances in  the  lower  extremities,  the  trunk,  the  superior  extremi- 
ties, the  neck,  and  face. 

In  cases  of  violent  nervous  headaches,  the  pain  very  generally 
radiates  to  the  scalp,  to  the  skin  and  deep-seated  tissues  of  the 
face.  Intense,  darting,  burning  pain  is  often  felt  in  the  eyeballs, 
or  deep  in  the  sockets  of  the  eyes ;  in  the  ears,  as  if  in  the  centre 
of  the  tympanum;  in  the  nose;  or  thrilling  along  the  dental 
nerves,  as  in  the  most  severe  forms  of  odontalgia;  not  unfre- 
quently  it  is  accompanied  with  the  most  acute  twitches  and 
spasms  of  the  facial  muscles,  thence  "tic  douloureux,"  as  it  has 
been  called  by  the  older  authors. 

The  motatory  system  is  often  disturbed  in  various  degrees, 
sometimes  most  horribly  without  any  tonic,  or  painful  spasms, 
as  has  been  described,  but  with  clonic  spasms  or  convulsions. 
Minor  examples  are  observed  in  the  irregular  twitchings  of  the 
eyebrows,  of  the  muscles  of  the  eyelids,  of  the  eyeballs,  and  occa- 
sionally even  of  the  tongue;  so  also  we  may  notice  all  the  varie- 
ties of  "  subsultus  tendinum,"  or  irregular  actions  of  the  mus- 
cular fibres  of  the  extremities,  to  the  most  rapid  convulsive 
disturbance. 

Cases. — In  one  case,  of  a  young  lady,  the  right  arm,  partially 
flexed,  was  raised  and  depressed  so  quickly  that  the  eye  could 
hardly  follow  its  motions.  There  were  simultaneous  agitations 
of  the  muscles  of  the  chest,  of  the  neck,  face,  and  eyes ;  often  a 


IXTERXAL    ORGAXS.  183 

similar  motion  begau  in  tiie  left  arm,  but  more  frequently  in  the 
right  lower  extremity,  especially  if  the  patient  attempted  to  stand 
or  walk.  All  this  occurred  without  pain,  or  loss  of  conscious- 
ness, but  always  with  some  peculiar  sensations  preceding  the 
attack,  which  were  mitigated  by  the  spasms.  These  last  were  a 
relief,  as  the  patient  observed;  so  far  were  they  from  being- 
accompanied  by  pain  or  mental  affection. 

In  another  case  of  an  unmarried  lady,  analogous  spasms  came 
on  almost  every  night,  in  paroxysms  of  eight  or  ten  hours'  dura- 
tion ;  during  these  paroxysms  the  knees  were  drawn  up  to  th6 
breast,  the  arms  clasped  tight  to  the  thorax,  and  the  head  bent 
over  the  breast,  and  all  the  muscles  kept  in  constant  agitation; 
but  the  functions  of  the  brain  were  apparently  undisturbed. 
These  paroxysms  did  not  come  on  in  the  day  time,  and  could 
soon  be  prevented  for  twenty-four  hours  by  attention  to  the 
uterus.  After  a  time  these  spasms  entirely  disappeared,  but  the 
patient  suffers  still  from  neuralgia  of  neck,  heart,  uterus,  etc. 

In  other  cases,  these  clonic  spasms  are  more  sudden  and  vio- 
lent, and  disturb  the  whole  body ;  it  cannot  be  kept  at  rest,  the 
patient  is  thrown  into  various  positions  for  hours  in  succession. 
Analogous  spasms  are  sometimes  confined  to  the  muscles  of  the 
spine. 

These  convulsions  may  come  on  at  irregular  intervals,  from 
accidental  causes ;  but  occasionally  thej^  occur  with  great  regu- 
larity at  the  catamenial  periods,  thence  their  evident  connection 
with  uterine  irritation. 


INTERNAL  ORGANS. 

During  the  existence  of  such  attacks,  the  patients  often  com- 
plain of  similar  spasmodic  sensations  about  the  oesophagus,  the 
larynx,  the  lungs,  the  heart,  the  diaphragm,  etc.,  which  they  call 
(perhaps  correctly)  internal  spasms.  They  are  not  dangerous  in 
themselves,  but  very  alarming  to  the  patient. 

The  practitioner  has  often  very  decided  proof  that  these  sensa- 
tions in  the  internal  organs  are  sometimes  to  be  relied  upon. 

Pharynx, — The  pharjmx  is  sometimes  thus  affected. 

Case. — A  patient  of  ours  was  unable  for  three  days  to  swallow 


1S4       EEFLEX    INFLUEXCES    OF    IRRITABLE    UTERUS. 

any  solid  or  fluid  matter.  The  moment  the  attempt  was  made,  a 
spasm  of  the  oesophagus  or  pharynx  forced  the  fluids  into  the 
larynx,  endangering  suffocation.  The  patient's  organic  functions 
were  perfectly  normal ;  she  suffered  from  neuralgia,  and  also 
from  the  distress  of  hunger  and  thirst.  The  inhalation  of  ether 
relieved  these  symptoms. 

Larynx. — Such  irregular  contractions  are  far  more  common 
in  the  muscles  of  the  larynx.  Hence,  in  some  nervous  patients, 
we  have  pure  examples  of  croup  without  any  inflammation,  and 
usually  spoken  of  as  "  laryngismus,"  "  spasmodic  croup."  It  may 
come  on  in  paroxysms,  after  longer  or  shorter  intervals,  with  the 
usual  distressing  symptoms,  so  alarming  to  patients  and  their 
attendants,  as  indicative  of  immediate  sufibcation.  Yet,  gene- 
rally, they  are  harmless  and  manageable.  Often  the  relief  is 
sudden  and  perfect.  After  the  paroxysm  there  is  no  impediment 
to  respiration,  and  no  hoarseness  remains ;  but  shortly,  however, 
they  may  return  with  all  their  original  severity. 

Organs  of  the  Chest. — The  sj^mptomatic  or  reflex  influences 
of  the  uterus  on  the  organs  of  the  chest  are  far  more  frequent  than 
on  the  larynx  or  pharynx. 

Respiratory  Function. — Every  variety  and  degree  of  disturbance 
of  the  respiratory  function  is  occasionally  observed,  with  or  with- 
out neuralgic  symptoms.  With  many  there  is  a  "tired  feeling" 
about  the  chest,  as  if  some  exertion  had  been  made  more  than 
usual,  or  as  if  a  deep  inspiration  or  sigh  was  absolutely  neces- 
sary. 

Cases. — A  lady  said  to  us,  that  she  dreaded  to  have  her  friends 
call,  it  was  such  a  fatigue  to  converse,  causing  a  sensation  of  ex- 
haustion about  the  neck  or  tracheal  region,  as  well  as  the  chest. 

In  another  case,  a  lady  stated  that  she  had  always  to  lie  down 
before  she  could  talk  with  her  friends. 

In  these  instances  the  tones  of  the  voice  were  clear  and  natural ; 
and  when  the  patient  became  interested,  no  signs  of  oppression 
existed. 

Often  there  is  also  a  sense  of  constriction  or  tightness,  as  if  a 
full  breath  could  not  be  taken.  In  many  there  is  always  a  sense 
of  oppression,  even  when  at  rest ;  in  others  it  is  paroxysmal ;  in 
some  periodical,  and  recurring  with  great  regularity.     It  is  occa- 


ORGANS    OF    THE    CHEST.  185 

sionally  mild  in  its  attacks,  but  sometimes  is  exceedingly  intense. 
This  great  sense  of  sufibcation,  of  distress,  combined  with  mental 
anxiety,  constitutes  the  worse  forms  of  "  spasmodic  asthma.''^  Such 
attacks  are  often  ephemeral,  perhaps  returning  daily,  sometimes 
at  longer  and  irregular  intervals.  Nevertheless,  a  sense  of  oppres- 
sion and  dyspnoea  is  seldom  absent ;  so  that  the  least  pain  or  irri- 
tation of  the  body,  or  any  agitation  of  the  mind,  will  bring  on  a 
paroxysm  of  asthma. 

Coughs. — Another  variety  of  nervous  irritation  of  the  lungs  is 
manifested  by  coughing.  There  are  a  great  number  of  these  ner- 
vous coughs,  and  some  of  a  most  peculiar  and  wonderful  charac- 
ter. A  simple,  dry,  hacking  cough,  scarcely  noticed  by  the 
patient,  is  perhaps  the  most  common,  Next  may  be  mentioned 
the  sonorous,  hard  cough,  as  if  through  a  metallic  tube,  appa- 
rently with  distress,  but  generally  without  any  suffering  or  anxiety 
on  the  part  of  the  patient.  Paroxysmal  coughs,  simulating  those 
in  pertussis,  are  not  unfrequent,  and  are  noticed  as  convulsive 
coughs.  The  patient,  for  hours,  may  have  been  comfortable,  and 
then  is  suddenly  seized  with  a  fit  of  coughing,  lasting  for  several 
minutes,  until  the  sufferer  seems  exhausted  by  fatigue. 

Case. — In  one  patient,  at  least,  we  have  known  the  paroxysm  to 
begin  moderately,  as  an  ordinary  coagh,  and  regularly  become 
more  and  more  rapid ;  until  the  distinction  of  sound  was  almost 
lost  in  one  continued  and  protracted  scream.  It  closely  resembled 
the  operation  of  the  steam-valve  in  a  locomotive  engine,  which, 
on  starting,  opens  and  shuts  slowly,  but  soon,  as  the  speed  in- 
creases, with  so  much  rapidity  as  to  defy  all  attempts  to  estimate 
the  frequency  of  its  operations.  These  have  been  termed,  vul- 
garly, "barking  coughs;"  they  are  often  very  loud  and  sonorous, 
so  as  to  attract  the  notice  and  excite  the  curiosity  and  anxiety  of 
neighbors  and  of  strangers. 

There  are  various  modifications  of  these  spasmodic  efforts,  in 
which  there  is  no  decided  cough  ;  but  the  inspiration  is  loud,  and 
the  expiration  prolonged  with  a  more  moderate,  yet  a  distinct, 
sound.  Such  attacks  are  often  periodical  for  months  in  succession  ; 
the  paroxysm,  coming  on  usually  in  the  morning,  will  generally 
last  for  eight,  ten,  or  twelve  hours,  after  which  the  breathing  and 
voice  will  become  perfectly  natural  until  the  same  hour  on  the 
succeeding  day. 


186       REFLEX    INFLUENCES    OF    IRRITABLE    UTERUS. 

In  some  patients  the  connection  with  uterine  irritation  is  so 
decided  and  manifest,  that  it  will  be  useful  to  record  the  facts. 

Cases. — A  large,  corpulent  lady,  whose  organic  actions  were 
perfect,  with  a  fine  color  and  other  evidences  of  health,  suffered 
from  neuralgic  and  spasmodic  complaints,  traceable  to  displace- 
ments of  the  uterus.  One  day,  after  we  had  entered  her  room,  she 
playfully,  but  in  all  earnestness,  exclaimed,  "  Doctor,  you  have 
given  me  a  violent  cough.  I  have  been  coughing  very  constantly, 
night  and  day,  since  your  last  visit."  "  Well,  madam,"  we  replied, 
"  if  we  gave  you  a  cough,  it  can  be  cured."  In  a  few  minutes, 
by  changing  the  uterine  support,  the  cough  disappeared,  and  did 
not  return. 

We  recall  two  other  cases ;  they  were  very  similar,  and  oc- 
curred in  women  long  sufferers  from  neuralgia.  A  cough  would 
continue  without  intermission  for  many  hours,  defying  the  ordi- 
nary appliances  of  anodynes,  demulcents,  etc.,  and  causing  great 
fatigue  and  exhaustion  to  the  patients.  They  could  not  take 
nourishment,  or  sleep,  from  its  persistence  and  severity.  On  two 
occasions,  we  have  known  the  paroxysm  to  continue  from  mid- 
day until  we  were  called  to  their  relief  at  midnight.  In  both 
patients,  relief  was  instantaneously  obtained  by  attention  to  the 
pelvic  irritation.  Each  of  these  patients  had  several  attacks  of 
this  character,  and  were  always  immediately  relieved  by  such 
manual  means,  without  the  assistance  of  medicine. 

An  unmarried  lady,  who  had  been  for  many  years  an  invalid, 
was  troubled  with  a  bad  cough,  with  short  and  oppressed  respi- 
ration, often  amounting  to  attacks  of  spasmodic  asthma.  She 
came  under  our  care  and  was  relieved  by  attention  to  irritations 
of  the  uterus.  She  remarked  that  she  had  just  been  amusing  her- 
self by  recounting  all  the  medicines  she  had  taken  for  pulmo- 
nary consumption.  She  stated  that  her  physician,  after  having 
treated  her  during  a  whole  winter  for  consumption,  had  inti- 
mated to  her  friends  that  she  would  soon  die,  as  medicine  could 
not  afford  relief.  Years  have  elapsed  since  the  uterine  irritation 
was  relieved,  and  no  pulmonary  symptoms  have  returned. 

Aphonia. — In  several  of  our  patients  perfect  aphonia  has  existed, 
apparently  from  inertia  of  the  respiratory  apparatus.  Sometimes 
for  days,  and  occasionally  for  weeks,  the  patient  can  speak  only 
in  whispers  and  with  considerable  effort.  This  aphonia,  also, 
will  often  suddenly  disappear. 


HEART.  187 

When  sncli  loss  of  voice  and  spasmodic  coughs  are  accompa- 
nied with  pain  about  the  chest,  and  aggravated  by  motion,  a  full 
inspiration  even  giving  pain,  they  have  often  been  mistaken  for 
inflammatory  complaints  of  the  muscles  of  the  chest,  or  of  the 
pleura,  bronchia,  or  lungs.  Such  a  mistake  is,  of  course,  pro- 
ductive of  great  detriment  to  the  patient,  and  discredit  to  the 
profession. 

Heart. — Disturbances  of  the  action  of  the  heart  from  various 
moral  causes,  as  fear,  joy,  anxiety  of  mind,  etc.,  are  familiar  to 
every  one,  especially  among  women.  Irritations  or  excitements 
of  the  brain,  from  physical  as  w^ell  as  moral  causes,  affect  the 
functions  of  the  heart.  This  is  very  frequently  exemplified  in 
all  the  varieties  of  uterine  irritation,  and  occurs  probably  through 
the  spinal  and  cerebral  systems.  In  cases  of  irritable  uterus, 
the  morbid  functions  in  the  cardiac  region  are  exceedingly  diver- 
sified and  rapidly  alternating.  The  heart,  for  hours  or  days  may 
give  no  disturbance ;  and  then  suddenly  the  slightest  cause,  it 
may  be,  Avill  excite  the  most  distressing  affections.  Patients 
continually  allude  to  a  fluttering  and  irregular  action  of  the 
heart,  to  palpitations  which  are  sometimes  very  violent,  with 
a  sense  of  suffocation,  of  fulness,  or  of  distension  as  if  rupture 
must  occur.  Hence,  there  are  great  secondary  disturbances  of 
the  brain  and  nervous  system  from  anxiety  of  mind,  and  dread 
of  a  speedy  dissolution.  Many  become  alarmed  under  an  idea 
of  the  heart  being  misplaced,  thrown  from  one  side  of  the  chest 
to  the  other,  while  others  insist  that  the  action  of  the  heart  at 
times  entirely  ceases.  In  most  of  these  cases  the  practitioner 
may  have  positive  evidence  of  cardiac  agitation,  by  placing  his 
hand  on  the  chest,  or  by  auscultation  when  the  palpitations  and 
irregular  actions  are  distinctly  felt  and  heard.  Yery  little,  how- 
ever, can  be  learned  from  the  pulse  at  the  wrist,  which  is  often 
perfectly  quiet,  soft,  and  regular  under  these  nervous  disturbances 
of  the  central  organ  of  the  circulation.  Sometimes,  it  is  corded, 
quick,  and  irritable,  perhaps,  from  the  general  disturbance  of  the 
nervous  system,  as  well  as  from  the  action  of  the  heart.  The 
diagnosis,  by  auscultation,  even  between  these  functional  or 
nervous  cardiac  excitements  and  the  indications  of  structural 
disease,  is  not  always  very  easy.  We  have  known  a  number  of 
cases,  where  even  experienced  auscultators  have  believed  that 
organic  disease  existed,  but  the  subsequent  result  did  not  justify 


188       REFLEX    INFLUENCES    OF    IRRITABLE    UTERUS. 

the  opinion.  When  these  irregular  actions  are  combined  with 
neuralgic  pains  in  the  tissues  of  the  chest,  physicians,  as  well  as 
patients,  have  apprehended  acute  inflammatory  affections  of  the 
heart,  or  of  its  external  or  internal  membranes.  The  distinction 
between  carditis,  pericarditis,  or  endocarditis,  and  mere  nervous 
disturbance  of  the  heart,  is  not  always  easily  drawn. 

Mammse. — In  connection  with  disturbances  of  the  chest  those 
of  the  mammee  or  breasts,  although  external  organs,  should  be 
noticed  in  this  place.  The  physiological  connection  of  these  glands 
with  the  uterus  is  familiar  to  all,  as  seen  in  their  contemporary 
development  at  puberty,  their  enlargements  and  increased  sensi- 
tiveness after  marriage,  especially  when  conception  has  occurred. 
These  physiological  states  of  the  mammse  are  types  of  the  patho- 
logical changes,  due  to  nervous  irritation  of  the  uterus.  The 
mammae  become  irritable,  that  is,  preternaturally  sensitive.  The 
patient  complains  of  soreness  if  touched,  and  sometimes  she  can- 
not even  bear  the  pressure  of  her  clothes,  or  any  movements  of 
her  arms.  The  glands  may  become  developed,  thence  "  hyper- 
trophy" of  these  organs.  One  gland  is  sometimes  larger  and  more 
tender  than  its  fellow,  the  proper  glandular  tissue  of  either  breast 
may  become  developed  irregularly,  even  in  virgins  and  married 
women  where  no  conception  has  occurred.  These  irregular  en- 
largements are  often  termed  "  tumors,"  to  the  great  alarm  of  the 
patient,  and  to  the  pecuniary  profit  of  charlatans,  or,  it  may  be,  of 
an  ignorant  surgeon. 

Cases. — A  patient  came  from  North  Carolina  to  Philadelphia, 
with  such  an  enlargement  of  the  left  breast,  accompanied  by 
some  soreness  and  hardness.  This,  and  a  similar  development 
in  the  right  breast,  had  been  termed  malignant  by  a  "  travelling 
cancer-doctor."  She  informed  us  that  several  of  her  acquaint- 
ances had  submitted  to  the  treatment  of  this  ignorant  pretender. 

Some  years  ago  we  attended  a  married  lady  from  the  valley 
of  the  Mississippi,  who  for  a  long  period  had  suffered  excessively. 
from  nervous  affections  due  to  uterine  disturbance.  After  some 
weeks,  she  called  our  attention  to  "  a  lump"  in  her  breast,  which 
she  said  was  sore  and  sometimes  painful.  After  having  examined 
it,  we  gave  the  opinion  that  it  was  of  no  importance,  and  would 
cause  no  serious  trouble.  She  was  much  surprised,  for  her  sur- 
geon had  twice  operated  on  this  very  breast  some  years  ago  for 
precisely  such  tumors ;  which  he  said  would  become  cancerous, 


VISCERA    OF    THE    ABDOME:^'.  189 

and  that  extirpation  was  demanded.  We  had  the  pleasure  of 
meeting  this  ladj  during  the  summer  of  1860.  She  had  gained 
flesh,  and  was  in  better  health  than  she  had  been  for  years,  and 
had  found  that  no  operation  upon  her  breast  was  needed. 

These  irregular  and  hardened  enlargements  of  the  mammge 
seem  very  analogous  to  the  tnastodynia  spoken  of  by  the  older 
writers  on  obstetrics,  as  a  symptom  or  consequence  of  pregnancy. 

The  preternatural  sensitiveness  of  the  mammas  and  their  de- 
velopments, seem  to  be,  as  formerly  mentioned,  prototj^pes  of  the 
irritable  uterus,  being  sometimes  merely  very  sensitive,  congested 
or  even  hypertrophied. 

Visceea  of  the  Abdomen. — Disturbances  in  the  functions  of 
the  viscera  of  the  abdomen,  from  uterine  irritation,  are  very  com- 
mon. Every  practitioner  of  obstetrics  is  perfectly  familiar  with 
the  sympathies  existing  between  the  organs  of  digestion,  and  those 
of  generation.  In  irritable  uterus,  these  sympathies  are  equally 
remarkable,  and  some  detail  will,  perhaps,  be  useful. 

The  neuralgic  pains  in  the  abdomen  have  already  been  noticed 
when  speaking  of  spinal  irritation.  These  pains  may  exist  in  any 
part  of  the  abdomen.  When  at  the  lower  part,  in  the  hypogastric 
and  iliac  regions,  they  are  often  to  be  traced  directly  to  the  uterus 
and  its  appendages ;  but  these  as  well  as  those  at  the  upper  por- 
tion, in  the  hypochondriac,  and  even  in  the  epigastric  regions, 
are  more  frequently  of  a  spinal  origin,  radiating  along  the  parietes 
of  the  abdomen.  Such  pains  are,  as  formerly  remarked,  too  fre- 
quently confounded  with  inflammatory  pains  indicating  visceral 
disease, 

/  Liver. — Pain  in  the  right  hypochondrium,  radiating  to  the  back, 
'  the  scapulae,  and  to  the  top  of  the  shoulder,  has  often  been  treated 
as  if  from  hepatitis,  and  the  treatment  continued  for  months  and 
years  without  avail.  The  mistake  has  been  the  more  readily 
made,  because,  in  many  instances,  there  is  also  torpor  of  the  liver, 
constipation  of  the  bowels,  nausea,  vomiting,  etc.  The  entire  ab- 
sence of  fever,  the  intermittent  character  of  the  pain,  and  its  fre- 
quent change  of  location ;  the  clearness  and  purity  of  the  com- 
plexion and  of  the  conjunctiva  of  the  eye;  and  the  normal  con- 
dition of  the  urine  and  other  secretions,  will  all  indicate  the 
neurotic  character  of  the  complaint.     The  diagnosis,  thus  formed, 


190       KEFLEX    INFLUENCES    OF    IRRITABLE    UTERUS. 

will  be  confirmed  by  the  fact  that  such  pains  usually  prove  in- 
domitable so  long  as  the  uterine  irritation  exists. 

There  is,  as  already  intimated,  generally  a  diminution  in  the 
biliary  secretion,  no  doubt  contributing  frequently  to  cause  torpor 
of  the  intestines.  This,  however,  is  not  connected  with  organic 
alterations  of  the  liver ;  for,  in  the  post-mortem  examinations  of 
those  who  had  suffered  for  many  years  with  affections  of  this 
kind,  the  liver  has  been  found  in  a  perfectly  normal  condition  as 
to  size,  color,  density,  etc. 

,  Stomach. — In  irritable  uterus  the  stomach  is  much  disturbed  in 
very  many  cases,  whether  by  a  direct  sympathy  or  through  the 
intervention  of  the  cerebro-spinal  system,  is  perhaps  a  matter  of 
small  moment.  In  many  patients,  of  course,  there  is  no  disturb- 
ance, they  may  have  an  excellent  appetite,  good  digestion,  and 
no  complaint  to  make  of  their  digestive  apparatus.  In  others, 
we  have  every  variety  of  nervous  dyspepsia.  Some  complain 
merely  of  a  sense  of  fulness  and  oppression  after  their  meals; 
with  them,  even  small  quantities  of  food  feel  heavy,  as  a  "  load" 
upon  the  stomach.  In  other  cases  there  is  a  loss  of  appetite,  a 
disgust  for  food,  even  the  smell  of  meats,  etc.,  is  often  disagree- 
able; there  are  heartburn  and  cardialgia  from  acid  accumulations, 
or  acrid  eructations,  especially  when  oily  and  other  animal  sub- 
stances have  been  taken. 

Nausea  is  not  uncommon,  and  is  often  followed  by  vomiting, 
either  of  the  contents  of  the  stomach  or  of  glairy,  serous,  or 
mucoid  matters,  and  occasionally  of  bilious  fluid.  Often  there  is 
great  straining  in  retching,  with  but  slight  ejection — the  so-called 
"  dry  vomiting" — gas  being  chiefly  thrown  off".  These  attacks  of 
nausea  and  vomiting  are  often  periodical,  coming  on  at  stated 
intervals,  then  disappearing  for  hours,  during  which  the  appetite 
and  digestion  may  be  comparatively  good,  and  then  again  suddenly 
returning.  We  have  known  regular  "morning  sickness,"  recurring 
for  months  in  young  girls,  from  uterine  irritation,  and  simulating' 
exactly  the  emesis  of  pregnancy.  The  effort  of  straining  and 
vomiting  aggravates  the  uterine  sufferings,  as  well  as  the  neu- 
ralgic pains  in  every  part  of  the  body. 

Perhaps  the  most  frequent  symptom  of  gastric  disturbance  is 
^flatulence.  This  is  an  evil  exceedingly  common,  and  is  by  no 
means  the  least  important  of  these  gastric  disorders,  or  the  most 
easily  to  be  overcome. 


TYMPANITES.  191 

f  Tympanites. — The  gas  is  seldom  confined  to  the  stomach,  but 
extends  throughout  the  whole  tract  of  the  intestinal  canal ;  hence 
it  may  be  considered  as  occupying  either  a  portion  or  the  whole 
of  the  alimentary  passages. 

Considerable  mystery  exists  as  to  the  causes  of  this  develop- 
ment of  gas.  Pathologists  usually  recognize  it  as  resulting  from 
the  decomposition  of  food,  which  has  not  been  properly  digested. 
Flatulence,  therefore,  is  a  very  common  result  of  indigestion. 
Doubtless  there  is  also  an  intimate  relation  between  the  genera- 
tion of  gas,  and  the  condition  of  the  nervous  system. 

Since  it  is  impossible,  in  the  present  state  of  our  knowledge, 
to  explain  how  gas  can  be  generated  through  the  agency  of  vital 
tissues,  many  have  met  the  question  with  a  positive  denial  as  to 
its  occurrence.  Yet,  that  gas  is  thus  formed,  at  times,  will  be 
evident  to  all  who  will  examine  the  subject.  We  are  at  present 
dealing  with  the  fact,  and  not  with  the  explanation.  Authors, 
old  as  well  as  recent,  have  recorded  cases  in  which  gas  has  been 
found  in  the  bloodvessels,  in  serous  and  other  cavities  of  the 
body,  where  there  had  been  no  decomposition  whatever,  and 
where  atmospheric  air  could  have  had  no  access.  Abdominal 
tympanites  embraces  one  variety  in  which  a  gas,  often  inodorous, 
has  been  largely  collected  in  the  cavity  of  the  peritoneum.  This 
is  known  by  post-mortem  examinations  to  have  occurred  in  cases 
where  no  perforation  of  the  alimentary  canal  existed ;  and  some- 
times where  no  special  disease  of  the  serous  membrane  could  be 
discovered.  In  an  autopsy  made  by  the  author,  on  opening  the 
cavity  of  the  abdomen  in  a  tympanitic  subject,  there  was  an 
immediate  collapse.  No  evidence  could  be  detected  of  either  a 
wound  or  ulcer  of  the  stomach  or  intestines,  and  these  organs 
afforded  no  evidence  of  having  been  themselves  distended.  The 
collapse  of  the  whole  abdomen  was  instantaneous,  upon  dividing 
the  parietes. 

All  surgeons  are  familiar  with  the  generation  of  gas  in  ab- 
scesses where  no  external  communication  existed. 

The  testimony  as  regards  mucous  surfaces  is  hardly  less  posi- 
tive, although  there  may  be  an  access  from  without.  Gas  is  often 
discharged  from  the  uterus  and  vagina,  not  only  as  an  occasional 
but  as  a  constant  symptom.  In  some  cases  of  irritation,  this 
occurs  when  there  has  been  no  decomposition  of  mucus,  blood,  or 
of  deciduous  membrane,  placenta,  or  other  portions  of  an  ovum. 


192       KEFLEX    INFLUENCES    OF    IRRITABLE    UTERUS. 

And  cases  of  regular  uterine  tympanites,  "  physometra,"  are  re- 
corded by  authors,  in  which,  owing  to  complete  obstruction  of 
the  canal  of  the  cervix  uteri,  the  whole  body  of  the  organ  was 
enlarged  from  the  accumulation  of  gas.  The  diagnosis  may  be 
made  positive  by  careful  digital  examinations,  internally  and  ex- 
ternally, assisted  by  percussion.  The  resonance  due  to  the 
uterine  tumor  can  with  care  be  distinguished  from  that  due  to  the 
intestines.  As  regards  the  alimentary  canal,  all  are  familiar  with 
the  sudden  generation  of  gas  in  all  the  varieties  of  hysteria, 
whether  excited  by  moral  or  physical  causes.  On  account  of 
sudden  fear,  great  anxiety,  sorrow,  or  grief,  nervous  paroxysms 
are  often  produced,  in  which  the  development  of  gas  will  often 
be  enormous,  even  when  no  food  exists  in  the  stomach.  In  many 
cases,  there  is  no  evidence  of  indigestion ;  and  perhaps  in  all 
cases,  the  gas  is  generated  too  suddenly  to  be  attributed  to  the 
fermentative  processes. 

..  In  uterine  irritation,  whether  symptoms  of  hysteria  be  present 
or  not,  gaseous  developments  iu  the  stomach  and  bowels  are  ex- 
ceedingly common.  Even  in  healthy  females,  when  no  evidence 
of  indigestion  exists,  intestinal  tympanites  of  a  moderate  character 
may  be  noticed  prior  to  the  occurrence  and  at  the  beginning  of 
the  catamenial  period.  They  speak  of  a  fulness  at  the  lower  part 
of  the  abdomen,  with  a  sense  of  distension,  weight,  or  pressure, 
which  usually  is  much  moderated  or  dissipated  by  a  free  flow  of 
the  menses ;  and  hence  this  fulness  and  distension  have  been  igno- 
rantly  ascribed  to  engorgement  of  the  bloodvessels  or  distension 
of  the  uterus :  yet,  that  it  is  gaseous  is  easily  verified  by  a  tactile 
examination  and  by  percussion.  It  is  the  result,  therefore,  of 
uterine  excitation,  and  not  of  uterine  congestion.  The  flow  re- 
lieves this  excitement,  and  the  intestinal  tympany  disappears. 

In  all  the  morbid  nervous  excitements  of  the  uterus,  similar 
phenomena  are  still  more  common.  As  one  of  our  patients  said, 
after  years  of  occasional  suffering,  generally  from  dysmenorrhoea:. 
"  Doctor,  there  is  no  doubt  about  it,  the  moment  I  feel  those 
uterine  pains,  I  have  wind  in  my  stomach."  The  feelings  of 
tightness,  of  fulness,  the  sense  of  oppression  and  weight  at  the 
epigastrium,  the  uneasiness  excited  immediately  after  eating  even 
small  quantities  of  food,  are  often  due  entirely  to  gaseous  accu- 
mulations, and  are  temporarily  relieved  by  carminatives  of 
,  various  kinds. 


FLATULENCE.  193 

So  also  in  dysmenorrboea  and  other  forms  of  uterine  irritation,  j 
large  quantities  of  gas  are  felt  in  the  intestines  by  the  patient, 
and  recognized  by  the  ear  and  touch  of  the  practitioner.  The 
noise  in  the  stomach  and  bowels  from  the  admixture  of  air  and 
the  fluids  in  these  viscera,  "borborygmi,"  as  it  is  termed,  is  audi- 
ble even  at  distances,  and  thence  mortifying  and  distressing  to  the 
patient,  especially,  as  is  not  unfrequent,  immense  quantities  are 
eructated  by  the  mouth,  or  ejected  per  rectum.  Continual  allu- 
sions have  been  and  will  be  made  to  gaseous  disengagements  in 
all  the  forms  of  uterine  disturbance  whether  of  nervous  or  inflam- 
matory character.  Hence,  not  only  in  dysmenorrhoea,  but  in  all 
the  varieties  of  irritable  or  inflamed  uterus,  in  metritis,  puerperal 
ovaritis,  and  peritonitis,  gaseous  distension  of  the  alimentary 
canal  is  one  of  the  most  frequent  symptoms.  Puerperal  fever 
without  tympanites  is  an  occasional  but  rare  circumstance. 

The  secondary — consequential  or  reactive  symptoms  of  flatu- 
lence— are  always   uncomfortable,  disagreeable,  and   sometimes 
of  the  most  severe  and  distressing  character,  in  nervous  affections ; 
and  in  inflammatory  diseases  they  often  hasten  the  dissolution  of  ' 
the  patient. 

In  the  stomach  we  have  already  alluded  to  the  feelings  of  oppres-'\ 
sion  and  distress  which  flatulence  produces,  often  followed,  as  they 
are,  by  nausea,  and  constant  ineffectual  retching — "  dry  vomiting." 
In  addition,  this  internal  distension,  like  pressure  from  without, 
aggravates  all  the  neuralgic  pains  of  the  parietes  of  the  abdomen 
and  chest.  Hence,  there  is  also  great  soreness  of  the  skin  over 
the  stomach,  ribs,  etc.,  so  that  the  patient  complains  of  the  slight- 
est pressure;  her  garments  must  be  loosened,  and  even  the 
weight  of  the  bedclothes  is  distressing.  Irregular  actions  of  the 
muscular  fibres  of  the  stomach  ensue ;  the  gas  cannot  escape ;  it 
is  locked  up  in  particular  portions  of  the  stomach ,  thence, 
spasms,  cramps,  "  gastrodynia,"  sometimes  of  the  most  intense 
character,  with  the  necessary  consequences  of  depression  and  ex- 
haustion, sometimes  even  of  convulsions.  Such  symptoms,  con- 
joined especially  with  cardialgia,  vomiting,  etc.,  simulate  gastritis^ 
and  are  also  often  confounded  with  peritonitis. 

Similar  phenomena  result  from  the  accumulation  of  gas  in  the^ 

intestines.     Here,  also,  we  observe  the  uncomfortable  distension; 

the  great  soreness  of  the  whole  cutaneous  tissue  of  the  abdomen ; 

the  same  intolerance  of  pressure  and  weight;  the  same  confine- 

13 


194       KEFLEX    INFLUENCES    OF    IKRITABLE    UTERUS, 

ment  of  the  gas  to  portions  of  the  intestines,  large  or  small,  but, 
perhaps,  most  frequently  to  the  C£ecum  or  sigmoid  flexure  of  the 
colon,  and  often  to  its  transverse  portion;  and  the  same  disposi- 
tion to  spasms  and  even  severe  colics.  Of  course,  all  the  local 
symptoms  of  uterine  irritation  are  also  exceedingly  aggravated. 
From  the  distension  of  the  intestines  and  the  spasmodic  action  of 
the  abdominal  muscles,  there  is  great  increased  pressure  upon  the 
uterus,  already  in  a  sensitive,  irritable  condition.  There  is, 
besides,  sympathetic  disturbance  of  the  uterus  and  the  bladder. 
Hence,  pains  and  cramps  of  the  uterus,  and  of  the  bladder,  are 
superadded  to  the  colics  of  the  intestines;  so  that  it  is  difficult  to 
determine  whether  the  bowels  or  the  uterus  are  most  in  fault. 
These  uterine  spasms,  or  "colics,"  as  they  have  been  termed,  are 
often  excited  by  intestinal  irritation.  The  distension  of  the  abdo- 
men, the  great  soreness  and  pain  on  pressure,  with  other  pheno- 
mena, have  too  often  been  regarded  as  evidences  of  inflammation; 
and  such  cases,  therefore,  have  been  confounded  with  enteritis, 
colitis,  or  peritonitis,  from  which  they  should  be  carefully  dis- 
tinguished. 
/^  Flatulence,  as   above   described,  may  be   regarded   as  active, 

^exciting  the  regular  peristaltic  motions  of  the  stomach  and 
bowels,  by  which  the  distension  may  be  diminished.  But,  there 
are  other  and  very  common  cases,  which  may,  not  inaptly,  be 
termed  passive.  In  these,  there  seems  to  be  but  little  resistance 
from  the  muscular  walls  of  the  intestines,  or  even  of  the  abdomen. 
In  such  cases,  the  gas  gradually  accumulates ;  there  is  a  passive 
distension  of  the  whole  abdomen,  sometimes  to  an  enormous 
degree,  without  any  spasms  or  irregular  action  of  the  stomach  or 
intestines,  without  "  borborygmi,"  and  with  little  or  no  escape  of 
gas  per  orem  or  per  anum.  This  state  of  things  constitutes  the 
'■'■  tympanites''''  of  nosologists.  Not  unfrequently  it  is  temporary, 
passing  away  in  a  few  hours,  or  a  few  days;  but,  occasionally, 
it  persists  even  for  years.  There  is  sometimes  not  much  dis- 
tress attending  it,  merely  an  uncomfortable  feeling  of  distension 
or  of  pressure;  but,  generally,  there  is  great  soreness  of  the 
abdomen,  and  even  of  the  skin.  The  patient  complains  of  the 
least  pressure  from  the  bedclothes,  or  from  the  hand,  so  that  a 
tactile  examination  can  with  difficulty  be  made.     Motion  even  in 

bed  is  painful;  the  patient  is  generally  found  lying  on  the  back, 
with  the  lower  limbs  flexed,  so  as  to  relax  the  abdominal  muscles 


ACTIVE    AND    PASSIVE    FLATULENCE.  195 

and  diminish  their  pressure.  She  is  not  conscious  of  the  cause 
of  the  distension;  but  imagines  it  must  be  from  tumors,  enlarged 
viscera,  or  dropsj,  or  even  pregnancy,  and  is  often  surprised  to 
hear  that  it  is  gas — "et  prseterea  nihih"  Generally,  there  is  loss 
of  appetite,  some  eructation  from  the  stomach,  and  occasionally 
nausea.  The  bowels  are  torpid ;  the  stools,  when  they  do  appear, 
are  small  in  quantity,  and  hard,  but  natural  as  to  color.  Here, 
also,  as  in  the  active  variety  of  flatulency,  this  distension  aggra- 
vates the  nervous  and  spasmodic  symptoms  of  other  parts,  par- 
ticularly of  the  uterus,  which  is  thus  pressed  down,  and  irritated.  , 
Hence,  there  is  great  increase  of  the  patient's  sufferings. 

That  these  passive  gaseous  accumulations  are  increased  bv' 
indigestion,  and  the  decomposition  of  food  and  drinks,  there  can 
be  no  doubt.  But  that  this  is  not  the  sole  cduse,  is  proved  by 
the  fact  that  the  tympany  will  continue  when  all  other  evidences 
of  indigestion  are  removed,  under  the  best  regulated  diet,  and  the 
best  remedial  agents;  that  it  is  often  persistent  for  a  long  period, 
until  indeed  there  is  a  rectification,  a  resuscitation  of  the  nervous 
energies  of  the  suffering  woman.  It  depends  on  the  nervous  state 
of  the  general  system,  often  connected  with  irritable  uterus  and 
its  appendages.  It  is  "nervous,"  or  "hysteric"  tympanites.  The 
diagnosis  is  not  always  easily  made,  especially  as  the  abdomen 
is  often  too  tense  and  too  sensitive  to  admit  of  a  careful  examina- 
tion, Eesonance  on  percussion  is  our  best  means  of  diagnosis: 
but  this  will  seldom  enable  us  to  say  positively,  whether  the  case 
be  nervous  or  inflammatory,  arising,  it  may  be,  from  chronic 
peritonitis.  It  is  dif&cult  to  determine  whether  enlargements  of 
the  liver,  spleen,  uterus,  or  tumors  of  the  uterus,  and  of  the  ova- 
ries, may  not  coexist.  The  diagnosis  may  sometimes  be  facili- 
tated by  examination  per  vaginam,  particularly  when  the  uterus 
or  ovaries  are  involved.  The  sound  will  be  of  great  assistance 
where  the  uterus  is  supposed  to  be  enlarged.  y 

Case. — An  unmarried  lady  was  once  brought  to  us,  who  for 
two  years  had  been  disabled  by  nervous  affections,  and  this 
painful  distension  of  the  abdomen.  She  was  am-emic,  pallid,  with 
no  appetite,  and  costive  bowels  ;  but  was  entirely  free  from  fever, 
and  was  in  no  degree  emaciated.  The  secretions  were  all  natural 
as  to  their  appearance,  except  that  of  the  kidneys,  which  was  very 
deficient,  so  that  for  two  or  three  days  no  micturition  occurred ; 
and,  by  means  of  the  catheter,  hardly  half  an  ounce  of  straw- 


196       REFLEX    INFLUENCES    OF    IRRITABLE    UTERUS. 

colored  urine  could  be  obtained.  Bj  a  vaginal  examination,  tbe 
uterus  was  found  to  be  small  and  slightly  prolapsed.  The  patient 
had  been  regarded  as  the  subject  of  abdominal  tumors,  but  sub- 
sequent observation  gave  the  negative  to  this  opinion ;  for  the 
whole  swelling  gradually  vanished  upon  attention  to  the  prolap- 
sus, and  no  tumor  could  be  found.  The  patient  returned  to  her 
usual  avocation  as  a  teacher  in  about  four  years  after  the  com- 
mencement of  her  disease. 

It  has  been  already  observed,  that  these  cases  have  been  some- 

Himes  mistaken  for  pregnancy,  both  by  patient  and  physician,  and 
hence  termed  "spurious"  or  "pseudo-pregnancy."    The  profession 

I  is  indebted  to  Sir  James  Simpson,  of  Edinburgh,  for  the  sugges- 
tion of  resorting  to  anassthesia  in  all  these  cases  of  passive  tym- 
panites in  order  to  assist  our  diagnosis.     Palpation,  under  these 

j  circumstances,  can  be  easily  and  freely  made,  especially  as,  accord- 
ing to  Dr.  Simpson,  there  is  a  partial  or  total  collapse  of  the  swell- 
ing, which,  however,  returns  when  anaesthesia  has  been  discon- 
tinued. 

Such  cases  may  be  occasionally  found  in  the  male  subject,  but 
are  more  frequent  in  women,  and  connected  generally  with  inter- 
nal irritation. 

Intestines. — In  nervous  affections  there  is  generally  a  torpor  of 
the  bowels,  giving  rise  to  obstinate  constipation.  This  is  well 
known,  but  authors  and  practitioners  have  unfortunately  differed 
as  to  the  cause.  Too  frequently,  it  has  been  regarded  as  dependent 
on  the  liver,  and  mercurials  have  been  freely  given,  and  often 
pushed  to  salivation,  to  the  great  detriment  of  the  patients.  That 
the  nervous  system,  through  the  medium  of  the  uterus,  is  usually 
in  fault,  is  proved  not  only  by  the  absence  of  the  common  symp- 
toms of  bilious  disorder,  but  by  the  coexistence  of  uterine  affec- 
tions, with  this  torpor  of  the  bowels  ;  and  by  the  fact  that  when 
the  uterine  trouble  ceases,  the  bowels  are  more  easily  regulated. 
In  some  cases,  the  intimate  connection  is  shown  by  the  rapidity 
in  which  constipation  appears  or  disappears  on  the  occurrence  or 
cessation  of  in-itations  of  this  organ. 

f  Thus,  a  lady  informed  us  that  her  bowels  ahvays  became  tor- 
pid when  she  had  monorrhagia,  and  on  its  cessation,  they  became 
regular.  In  dysmenorrhoea,  constipation  is  much  more  common 
at  the  period  than  at  other  times.  It  is  found  also  that,  in  all  the 
varieties  of  hysteria,  torpor  of  the  bowels  is  frequently  observed. 


INTESTINES.  197 

The  consequences  of  constipation  are  well  known.  This  state  in- 
creases the  tympanites,  the  indigestion,  the  loss  of  appetite,  and 
the  disposition  to  gastrodynia,  and  to  colic ;  as  well  as  aggravates 
the  soreness  from  distension,  and  the  sensitive  and  neuralgic  state 
of  the  tissues.  In  various  ways  it  also  augments  the  displacements 
and  irritations  of  the  uterus.  The  mere  attempt  to  pass  scybalous 
matters  from  the  rectum,  as  formerly  mentioned,  will  sometimes 
cause  the  most  intense  agony,  and  still  more  frequently,  will  be 
followed  by  sensations  of  great  languor  and  prostration.  The 
injurious  effects  of  sedation  of  the  bowels  upon  the  liver,  lungs, 
heart,  brain,  and  other  viscera,  are  well  known. 

It  is  wonderful  how  the  general  health  and  flesh  of  the  patient 
will  sometimes  be  maintained  for  months  and  years,  where  affec- 
tions of  the  womb  exist,  complicated  with  more  or  less  dyspepsia, 
torpor  of  the  liver  and  of  the  bowels,  neuralgic  spasmodic  irrita- 
tions of  various  tissues,  and  sometimes  even  violent  convulsions. 

When  the  appetite  and  digestion  remain  good,  these  patients 
often  exhibit  all  the  symptoms  of  perfect  health,  as  regards  the 
organic  life,  having  plenty  of  red  blood,  free  secretions,  full  nutri- 
tion, abundant  development  of  their  tissues  and  organs,  and  a 
superabundance  of  fatty  deposits.  Some  of  the  healthiest  looking 
women  become  martyrs  to  nervous  affections ;  indeed,  the  most 
severe  sufferers  we  have  seen,  have  been  in  excellent  condition  as 
regards  their  circulatory  and  organic  functions.  Still,  however, 
from  confinement  to  the  house,  from  the  disturbance  of  the  func- 
tions of  the  digestive  organs,  many  nervous  patients  are  thin, 
pallid,  anasmic,  sometimes  chlorotic.  And,  on  the  other  hand, 
there  are  great  numbers  of  cases  of  ansemia  where  there  is  no 
peculiar  excitability. 

These  facts  are  very  common,  but  are  too  often  forgotten ;  so 
that  the  practitioner  regarding  the  debility  and  anaemia  as  all  im- 
portant, resorts  merely  to  nutritious  diet,  tonics,  and  stimulants, 
without  inquiring  into  the  local  causes  of  evil.  Or,  on  the  other 
hand,  in  the  healthy  looking  individual,  he  is  sometimes  led  to 
treat  her  simply  for  her  mental  and  physical  excitements,  and  her 
local  irritations  by  depletory  measures,  without  remembering  that 
the  more  she  is  exhausted,  the  more  sensitive  she  becomes.  Ana3- 
mia  is  not,  properly,  the  cause  of  nervous  affections,  but  one  of 
their  frequent  and  indirect  results.  It  may  thus  arise  from  loss 
of  appetite,  or,  at  least,  from  impaired  digestion,  imperfect  assimi- 


198       KEFLEX    INFLUENCES    OF    IRRITABLE    UTERUS. 

lation  and  long  confinement,  and  tlius,  from  sympathy  of  tlie 
organs  of  digestion,  with  the  uterus,  through  the  medium  of  the 
nervous  system.  Nervousness,  or,  more  properly,  irritability,  of 
the  cerebro- spinal  system  is,  therefore,  the  cause  of  anaemia, 
through  the  medium  of  the  digestive  organs,  whose  functions 
are  diminished ;  because  the  patient,  in  consequence  of  suffering, 
is  deprived  of  fresh  air  and  exercise.  Some  practical  deductions 
will  hereafter  be  made. 

In  pure  nervous  affections,  the  stomach  and  bowels  are  thus 
sympathetically  disturbed  by  the  uterus,  so  that  this  disturbance 
appears  and  disappears  with  the  presence  or  absence  of  pelvic 
irritation ;  yet  in  many  of  the  chronic,  long  protracted  cases  of 
confinement  to  the  house  or  bed,  secondary  symptoms  of  a  more 
inflammatory  and  dangerous  character  may  be  developed.  Evi- 
dences of  phlogosis  are  occasionally  perceived  throughout  the 
whole  tract  of  the  alimentary  canal,  usually  commencing  at  the 
stomach  and  spreading  either  upwards  towards  the  mouth,  or 
downwards  along  the  intestines.  Hence  we  have  chronic  stomatitis 
and  pharyngitis,  often  with  aphthous  or  albuminoid  deposits, 
sometimes  with  vesicles  or  in  pustules,  and  enlargement  of  the 
muciparous  glands,  resembling  tubercles.  The  same  varieties  of 
irritation,  under  the  names  of  cesophagitis,  gastritis,  enteritis,  coli- 
tis, and  rectitis,  are  sometimes  observable  throughout  the  whole 
tube,  with  the  usual  symptoms  of  anorexia,  cardialgia,  nausea, 
diarrhoea,  and  dysentery.  They  are  all  of  a  chronic  character, 
and  sometimes  exhaust  and  destroy  the  vital  powers  of  the  un- 
happy patient.  In  the  post-mortem  examinations,  the  customary 
results  of  the  inflammatory  process  may  be  seen  in  the  discolora- 
tion of  the  mucous  membrane,  the  morbid  exudations,  the  gland- 
ular enlarorements  and  ulcerations. 

Happil}^,  these  inflammations  are  not  frequent,  and  can  usually 
be  relieved;  but  when  neglected  or  improperly  treated,  may 
prove  fatal.  They  are  not  necessarily  connected  with  uterine 
irritations,  but  are  accidental,  and  occur  secondarily ;  as  in  all 
chronic  affections,  where  the  patients  have  long  been  confined, 
and  when  there  is  a  want  of  appetite,  digestion,  and  assimilation. 
The  blood,  of  course,  is  impoverished,  and  thence  the  secretions 
themselves  become  acrid  and  irritating  to  the  tissues,  especially 
to  the  mucous  membranes.  To  this  is  constantly  added  the  irri- 
tation from  food  and  drinks  which  have  not  been  digested,  and 


KIDNEYS.  199 

even  this  is  too  frequently  increased  by  the  improper  exhibition 
of  drugs.  Herpetic  eruptions  on  the  skin,  especially  about  tlie 
mouth,  eyes,  ears,  vulva,  or  anus,  are  also  manifestations  of  the 
same  deteriorated  condition  of  the  fluids,  and  evidences  of  the 
same  cachectic  state  of  the  system.  The  wonder  is,  not  that  such 
patients  should  die,  but  that  many  should  survive,  and  that  some 
should  eventually  recover. 

Kidneys. — The  kidneys  are  also  much  involved  in  all  nervous 
affections,  especially  in  women ;  but  to  what  extent  is  not  easily 
ascertained.  In  the  ordinary  condition  of  most  nervous  patients, 
there  is  no  disturbance  of  the  renal  functions,  as  indicated  by 
pain,  or  the  character  of  the  urine.  But  after  severe  cephalalgia, 
asthma,  or  any  of  the  decided  forms  of  hysteria,  there  is  often 
a  rapid  secretion  of  colorless  urine,  resembling  pure  water. 
Pints,  or  even  quarts  are  sometimes  discharged  in  a  few  hours, 
apparently  to  the  great  relief  of  the  patient.  It  is  the  "  diabetes 
serosa"  of  systematic  authors,  and  seems  to  be  a  "critical  dis- 
charge ;"  the  paroxysm  being  partially  or  completely  relieved. 
No  permanent  benefit,  however,  results. 

There  are  few,  if  indeed  any  other  evidence  of  kidney  affection ; 
as  the  pains  often  experienced  in  the  sides  and  back  can  hardly 
ever  be  referred  to  the  kidneys.  They  are  changeable  in  their 
•location,  and  seldom  exist  in  the  region  of  these  viscera;  with  the 
above  exception,  there  is  ordinarily  no  disturbance  of  their  secre- 
tory functions.  We  have  known,  in  the  most  agonizing  attacks 
of  neuralgia  of  the  uterus  and  of  dysuria,  the  appearance  and  the 
chemical  qualities  of  the  urine  to  remain  unchanged.  Of  course, 
there  are  many  apparent  exceptions  to  this  remark,  as  the  urine 
is  frequently  affected  by  the  ever- varying  condition  of  the  sto- 
mach, liver,  kidneys,  and  the  blood ;  but  these  variations  are  ac- 
cidental, and  arise  from  complications  more  or  less  transitory. 

The  common  impression  seems,  however,  to  be  the  reverse  of 
this.  Women  themselves,  especially,  are  continually  alluding  to 
"  kidney  pains"  and  "  kidney  affections,"  in  speaking  of  their 
nervous  symptoms.  This  arises,  no  doubt,  partly  from  ignorance, 
and  partly  from  modesty ;  for  it  will  be  discovered,  that  under 
the  above  expressions,  they  allude  to  the  bladder  and  its  disturb- 
ances. Hence  they  often  use  these  terms  to  speak  of  the  burning 
pain  about  the  urethra  and  bladder,  the  constant  inclination  to 
urinate,  the  neuralgic  and  spasmodic  sufferings  in  dysuria  and 


200       EEFLEX    INFLUENCES    OF    lERITABLE    UTERUS, 

strangury.  All  these,  however,  are  dependent,  not  on  any  morbid 
character  of  the  urine,  not  on  the  condition  of  the  kidneys,  or 
even  on  the  blood,  but  on  local  states  of  the  bladder  or  uterus, 
as  was  formerly  detailed.  In  a  few  rare  cases,  we  have  found 
purulent  discharges  from  the  bladder,  evincing  inflammation  as 
from  cystitis,  in  some  instances,  and  nephritis  in  others.  In  one 
case,  that  we  recall,  the  result  was  fatal,  from  rapid  enlargement 
and  disorganization  of  the  left  kidney,  as  far  as  could  be  ascer- 
tianed  during  life,  for  no  post-mortem  examination  was  obtained. 
In  pure  nervous  affections  there  is  occasionally  a  torpor  of  the 
kidneys,  the  secretion  of  urine  being  very  sparse.  A  case  has 
already  been  adduced,  in  which,  for  hours,  or  even  days,  no  mic- 
turition took  place,  and  the  catheter  could  extract  but  a  small 
portion  of  healthy  urine.  Nevertheless,  the  complications  of 
nervous  affections  with  the  disturbances  of  the  stomach,  liver, 
kidneys,  and  other  organs,  as  well  as  with  the  condition  of  the 
blood  itself,  give  rise  to  altered  states  of  the  urine.  Hence,  in- 
crease of  its  saline  contents,  alterations  in  color,  the  deposits  of 
mucus,  of  pus,  of  epithelial  scales  from  the  bladder,  ureters, 
pelvis,  etc.  of  the  kidneys,  the  presence  of  albumen,  etc.,  may  all 
be  occasionally  met  with,  indicating  complications  of  a  more  or 
less  serious  character,  which  demand  special  attention  from  the 
physician. 


ORGANIC  LIFE  SOMETIMES  IXVOLVED. 

We  have  now  presented  a  succinct  account  of  the  sympathetic 
or  general  symptoms  of  irritable  uterus.  We  have  exhibited 
their  true  essential  character,  as  depending  on  the  cerebro-spinal 
nervous  system,  without  necessarily  involving  the  organic  life, 
whose  actions  are  often  perfect  when  the  animal  life  suffers  even 
severely. 

Nevertheless,  such  is  the  intimate  connection  and  mutual  de- 
pendence of  these  two  distinct  systems  on  each  other,  that  some 
disturbance  of  the  circulation  is  observable  very  frequently  in 
nervous  affections.  This  has  already  been  dwelt  upon  in  the 
first  chapter,  and  afterwards  illustrated  as  far  as  the  uterus  was 
concerned,  under  the  head  of  local  symptoms. 

What  is  true  of  the  uterus  is  true,  cseteris  ^mriSt^s,  of  other 


ORGANIC    LIFE    INVOLVED,  201 

tissues  and  organs.  In  the  cerebral  irritations,  sympathetic  of 
uterine  disturbance,  we  have,  for  example,  not  merely  neuralgia, 
cephalalgia,  delirium,  and  other  nervous  symptoms ;  but  we  have 
also  in  some  cases  irregularities  of  the  circulation.  The  pulse  is 
usually  soft  and  free  from  irritation,  even  during  the  paroxysms 
of  pain;  occasionally,  however,  it  is  more  frequent  than  natural. 
But  very  generally  there  is  coldness  and  pallor  of  the  upper  and 
especially  of  the  lower  extremities,  while  the  face  is  flushed,  the 
eye  often  injected,  and  there  exists  a  more  or  less  turgid  condi- 
tion of  the  superficial  vessels  of  the  neck,  chest,  etc.  There  is 
doubtless  a  similar  active  congestion  of  the  internal  tissues  of  the 
cranium,  but  generally  in  a  moderate  degree.  Even  in  the  se- 
verer forms  of  hysteria,  when  stupidity,  or  delirium,  or  convul- 
sions ensue,  the  engorgement  is  not  often  of  a  serious  character. 
No  practitioner  dreads  the  result  of  such  attacks;  very  few 
patients  perish  in  hysteric  convulsions ;  doubtless,  because  the 
congestion  is  comparatively  trifling,  while  the  nervous  irritation 
is  severe  and  prominent. 

By  way  of  illustrating  this  idea,  attention  might  be  fixed  for  a 
moment  on  puerperal  convulsions,  which  are  ahvays  dangerous 
and  too  frequently  fatal.  After  much  anxious  experience  and 
reflection,  it  is  evident  to  our  mind  that  there  is  no  essential 
pathological  difference  between  the  usual  form  of  puerperal  con- 
vulsions and  those  which  occur  in  the  non-parturient  state  in 
hysterical  women.  We  have  seen  so  many  cases  in  the  latter 
precisely  similar,  as  regards  their  phenomena,  at  the  time  and 
after  the  attack,  to  those  of  the  former  ;  and  so  many  of  the  puer- 
peral form  resembling  those  of  the  hysteric  as  to  the  precursory, 
attendant  and  consecutive  symptoms,  that  we  must  believe,  that 
pathologically  they  are  virtually  the  same.  The  only  real  differ- 
ence is  the  degree  of  congestion  ;  this  being  comparatively  trifling 
in  the  unimpregnated  state,  very  great  during  gestation,  and  still 
more  so  during  labor.  The  engorgement,  in  this  case,  arises 
from  the  almost  universal  plethoric  state  of  pregnant  women 
("hypersemia"  seu  "  hydrsemia"),  which  during  kbor  is  enhanced, 
particularly  as  regards  the  brain,  by  the  "pains"  and  the  bearing- 
down  efforts;  these  include,  of  course,  the  holding  of  the  breath, 
the  temporary  suspension  of  respiration,  and  the  consequent 
passive  congestion  in  the  lungs,  right  side  of  the  heart,  the  brain, 
etc.     Hence,  the  danger  and  fatality  of  puerperal  convulsions. 


202       REFLEX    INFLUENCES    OF    IRRITABLE    UTERUS. 

The  origiiia]  nervous  irritation  is  aggravated  by  this  congestion, 
so  that  effusion  of  serum  or  blood  may  ensue,  and  the  patient 
become  comatose,  and  die. 

In  hysteric  convulsions  there  is  nervous  irritation,  but  the  con- 
gestion is  moderate;  and  although  it  aggravates  the  nervous 
symptoms,  yet  very  rarely  is  there  effusion,  serious  mischief,  or 
death.  Such  cases  are  usually  and  safely  treated  as  nervous  irri- 
tations; although,  sometimes,  the  plethora  and  congestion  are  so 
great  as  to  demand  depletion.  In  puerperal  cases,  however, 
depletion  is  very  generally  necessary  for  the  safety  of  the 
patient,  to  relieve  congestion  and  prevent  effusion.  Yet  in  some 
of  the  milder  forms  of  this  complaint,  which  have  indeed  been 
termed  "  hysterical  puerperal  convulsions"  by  the  systematic 
authors  (as  if  different  in  their  nature  from  the  congestive), 
patients  have  recovered  under  the  treatment  for  nervous  irrita- 
tion. These  observations  are  predicated,  let  it  be  observed,  upon 
the  idea  that  puerperal  convulsions  are  dependent  not  on  toxi- 
c^mia,  but  on  plethora  or  inordinate  fulness  of  the  bloodvessels. 

What  is  thus  exemplified  by  the  condition  of  the  brain  in  nerv- 
ous affections  from  irritation,  is  true  also  of  the  other  organs  of 
the  economy.  In  the  brain,  however,  the  centre  and  source  of 
nervous  influence  locked  up  in  a  bony  casket,  and,  therefore,  in- 
capable of  distension,  the  indications  of  nervous  irritation,  and 
the  aggravation  by  the  engorgements  of  its  vessels,  when  con- 
gested, are  comparatively  very  great.  In  nervous  irritation  of 
the  larynx,  of  the  lungs,  and  of  the  heart,  there  is  frequently  con- 
gestion ;  but  generally  it  is  not  severe,  and  is  seldom  followed  by 
any  bad  consequences.  It  is  an  error  too  common  to  regard  the 
croup,  the  asthma,  etc.,  as  essentially  congestive  or  inflammatory. 
Their  essential  character  is  nervous,  the  engorgement  being  second- 
ary and  usually  of  minor  importance.  In  very  plethoric  habits, 
or  in  pregnancy,  the  congestion  is  greater,  and  may,  as  in  cerebral 
irritation,  sometimes  demand  primary  and  paramount  attention.    ■ 

As  regards  the  lungs,  more  especially,  effusions  of  serum,  mu- 
cus, and  blood,  occur  in  the  bronchial  tubes,  which  may  then  be 
expectorated,  to  the  relief  of  the  congestion,  or,  if  profuse,  may 
cause  asphyxia  and  death. 

Similar  observations  may  be  made  of  the  irritations  of  the  ab- 
dominal viscera.     The  nausea,  the  vomiting,  the  constipation,  the 


ORGANIC    LIFE    IXVOLYED.  203 

flatulency,  the  tj'-mpanites,  the  gastrodjnia,  the  colics,  etc.,  although 
essentially  purely  nervous,  yet  are  occasionally  enhanced  by  con- 
gestion. In  some  rare  cases,  this  congestion  is  relieved  by  the 
effusion  of  blood  from  the  stomach,  bowels,  hsemorrhoidal  vessels, 
etc.,  and  occasionally  by  increased  secretions.  In  some,  this  is 
manifested  by  the  emesis  of  mucoid  and  seroid  fluids,  or  by  that 
Avatery  eructation  termed  "  water-brash." 

Cases. — One  lady  has  lately  informed  us,  that  for  years  a  de- 
cided serous  diarrhoea  with  her  was  frequently  the  result  of  uterine 
irritation.  In  another,  obstinate  chronic  diarrhoea,  at  about  the 
forty-fifth  year  of  life,  was  evidently  a  substitute  for  the  catame- 
nial  discharge.  It  was  really  a  case  of  vicarious  menstruation, 
and  disappeared  gradually,  as  the  patient  recovered  from  the  ute- 
rine irritation,  and  the  effects  of  the  cessation  of  the  menses.  In 
a  third  case  there  is  endometritis  superadded  to  irritable  uterus ; 
the  patient  says  that  almost  any  exercise  will  produce  pelvic  pain, 
and  be  followed  by  a  laxative  stool,  not  serous,  but  feculent  and 
pultaceoiis.  Sometimes  the  discharges  are  more  of  a  bilious 
character,  and  occasionally  accompanied  by  tenesmus. 

All  these  examples  are,  however,  exceptions  to  the  general 
condition  of  the  intestines  in  nervous  affections,  namely,  that  of 
constipation.  But,  even  a  great  degree  of  costiveness,  not  unfre- 
quently,  alternates  with  diarrhoea ;  and  there  are  many  females 
who  can  never  suffer  from  mental  agitation  without  having  sub- 
sequently a  diarrhoea. 

The  pure  limpid  urinary  secretion,  which  flows  so  abundantly 
after  paroxysms  of  nervous  irritations,  performing  the  part  of  a 
critical  evacuation,  evinces  also  a  prior  engorgement  of  the  renal 
vessels,  as  connected  with  the  nervous  irritation,  and  hence  the 
pabulum  or  material  for  this  extraordinary  secretion.  Neverthe- 
less, all  these  engorgements,  with  comparatively  few  exceptions, 
are  moderate ;  often,  they  are  not  to  be  detected,  and  of  course 
but  seldom  demand  very  positive  remedial  measures.  The  essen- 
tial character  of  the  complaints  is  nervous,  located  in  the  cerebro- 
spinal system,  and  is  produced  and  maintained  by  some  local 
irritation,  which  is  often  apparent,  but  occasionally  obscure  and 
mysterious,  so  as  to  avoid  detection  by  the  united  agencies  of 
science  and  experience.  Still,  these  congestions,  when  apparent, 
demand  attention,  as  they  aggravate  the  nervous  irritation,  and 


20-i       REFLEX    INFLUENCES    OF    IRRITABLE    UTERUS. 

often  give  rise  to  effusions.  This  is  especially  true  when  the 
uterus  is  involved,  as  then  menorrhagic  or  leucorrhceal  discharges, 
and  in  cases  of  enteric  irritation  and  congestion,  as  hemorrhagic 
or  seroid  evacuations  ensue ;  which  directly  debilitate,  and  thus 
indirectly  render  the  general  system,  as  well  as  the  individual 
organs,  more  and  more  irritable. 


PROGRESS    AND    RESULTS    OF    IRRITABLE    UTERUS.      205 


CHAPTER   YII. 

PROGRESS  AND  RESULTS  OF  IRRITABLE  UTERUS. 

The  progress  and  results  of  this  nervous  condition  of  the 
uterus  have  been  perhaps  sufficiently  elucidated  by  the  above 
history  of  the  local  and  general  symptoms.  A  few  more  details 
may,  however,  be  advantageously  given. 

In  a  large  number  of  women,  this  disease  exists  in  a  very  mild 
form ;  so  mild  as  frequently  not  to  excite  even  the  suspicion  that 
the  uterus  is  the  origin  of  the  evil.  When  perfectly  quiet,  they 
have  no  complaints,  or  can  readily  bear  moderate  mental  or  cor- 
poreal exertion.  If,  however,  a  long  drive,  or  especially  a  long 
walk  be  taken,  they  feel  very  "weak,"  or,  more  correctly,  very 
languid,  exhausted,  with  sensations  of  "  sinking,"  "  of  giving 
way ;"  sometimes  faintness,  and  occasionally  actual  syncope 
ensue.  Rest  but  partially  restores  their  energies ;  it  is  still  an 
effort  to  move,  to  leave  their  beds  in  the  morning,  or  to  resume 
their  daily  avocations.  They  become  less  interested  in  reading, 
find  it  an  effort  to  fix  their  attention  on  their  work,  to  listen  to 
the  conversation  of  their  friends,  or  even  to  endure  their  society. 
They  become  low-spirited,  and  are  easily  disturbed  by  trifles. 
They  wonder  what  makes  them  so  weak,  and  so  indift'erent ;  they 
have  no  pain,  no  positive  local  trouble,  unless  it  be,  after  exer- 
cise, a  sensation  of  weakness  in  the  back,  or  fulness  in  the  lower 
part  of  the  abdomen.  Nevertheless,  days  and  months  pass  away, 
and  they  can  gain  no  strength  under  the  most  skilful  employment 
of  a  good  diet,  tonics,  stimuli,  exercise,  travel,  and  social  inter- 
course. 

Under  such  circumstances,  a  long  walk,  dancing,  jumping, 
marriage,  or  any  other  exciting  cause,  aggravates  the  sensibility 
of  the  uterus,  the  pain  in  the  sacrum,  in  the  abdomen,  etc.  At 
the  catamenial  periods,  symptoms  of  dysmenorrhoea  or  menor- 
rhagia  appear,  and  are  followed  by  leucorrhoea,  with  more  or 
less  development  of  the  sympathetic  symptoms  of  spinal  and 


206      PROGRESS    AND    RESULTS    OF    IRRITABLE    UTERUS. 

cerebral  irritation.  The  local  trouble  is  by  no  means  confined 
to  the  uterus,  but  extends  to  the  adjacent  organs,  the  rectum,  the 
vagina,  and  the  bladder,  involving,  in  all  cases,  directly  or  indi- 
rectly, the  sacral  nerves.  These  last  often  become  so  sensitive, 
that  the  least  pressure  upon  them  from  a  displaced  uterus,  or 
feculent  matters  in  the  rectum  will  give  intense  pain,  radiating 
towards  their  sentient  extremities,  or  in  the  reverse  direction, 
towards  their  centres  or  origins  in  the  spinal  marrow  or  brain. 


IRRITABLE  RECTUM. 

IrritaUe  Rectum  is,  therefore,  a  common  sequence  of  irritable 
uterus,  but  may  arise  from  other  causes.  Among  these  are  dis- 
placements of  the  uterus,  it  may  be  a  prolapsus  or  retroversion, 
pressing  upon  the  rectum,  even  when  the  uterus  itself  is  not  very 
sensitive ;  the  presence  of  ascarides,  or  other  vermes ;  as  well  as 
morbid  secretions,  undigested  food,  etc.  It  is  sometimes  the 
result  of  rectitis  after  the  symptoms  of  inflammation  have  dis- 
appeared, while  the  nervous  susceptibility  still  remains. 

The  sy^nptoms  are  well  marked.  They  are  usually  such  as  sen- 
sations of  weight,  fulness,  tenesmus,  frequent  but  ineffectual  incli- 
nations to  stool,  the  discharge  of  seroid  or  mucoid  fluids,  painful, 
sometimes  agonizing,  defecation,  great  distress,  and  often  pain 
from  all  kinds  of  euemata,  not  excepting  in  some  cases  those  of 
an  anodyne  character.  The  presence  of  the  injecting  pipe,  or  the 
least  distension  of  the  bowel,  often,  cannot  be  borne.  Exami- 
nation by  the  finger,  in  bad  cases,  is  actually  intolerable,  and 
excites  terrific  outcries  from  the  patient,  with  many  hysterical 
symptoms ;  especially  when  irritation  of  the  rectum  is  compli- 
cated with  irritable  uterus,  and  the  finger  is  carried  to  the  ante- 
rior part  of  the  rectum,  against  this  organ.  The  orifice  of  the 
rectum  is  also  very  sensitive  to  a  tactile  examination,  and  to  the 
passage  of  fceces,  etc. 

In  these  cases  more  or  less  congestion  is  apt  to  ensue;  hence 
occasionally  there  are  bloody  effusions ;  hence  also  turgescence  of 
the  hsemorrhoidal  veins,  their  protrusion  when  straining  is  induced, 
their  stricture  by  the  sphincter  ani,  their  further  turgescence,  and 
consequent  inflammation  or  rupture,  constituting  the  two  varieties 


lERITABLE    RECTUM.  207 

of  inflamed  or  "  blind"  piles,  and  of  "  bloody"  piles.     Haemor- 
rhoids may  thus  be  a  sequence  of  irritable  uterus  or  rectum. 

The  diagnosis  of  irritable  rectum  is  by  no  means  easy  without 
careful  examination,  especially  as  regards  rectitis,  of  which,  as 
already  stated,  it  is  sometihies  the  sequence.  Negatively,  it  may 
be  distinguished  from  dysentery  by  the  absence  of  chill,  of  fever, 
and  emaciation;  also  by  the  non-appearance  of  purulent  or  lym- 
phatic discharges  per  rectum,  and  indeed  of  all  the  symptoms  of 
colitis.  More  positively,  it  may  be  recognized  by  the  healthy 
character  of  the  mucoid  and  seroid  evacuations;  by  the  regular 
discharges  o^'f  natural,  well-formed  feculent  stools ;  by  the  absence 
of  pain  and  even  of  tenesmus,  so  long  as  the  rectum  is  kept  per- 
fectly at  rest;  by  the  invariable  return  of  severe  pain,  on  motion 
of  the  patient,  on  defecation,  or  on  distension  of  bowels  by  ene- 
mata,  etc.;  by  the  limited  extent  of  this  pain  in.  the  region  of  the 
sacrum,  coccyx,  posterior  perineum,  and  even  of  the  uterus,  with- 
out any  of  the  peculiar  griping  "  cutting"  pains  in  the  hypogas- 
tric region  so  common  in  dysentery. 

In  chronic  cases,  the  diagnosis  is  more  easily  established  by 
the  organic  health  of  the  sufferer,  who  maintains  in  many 
instances  a  good  color,  a  good  appetite  and  digestion,  and  an 
abundance  of  flesh  and  strength.  The  normal  character  of  the 
mucous  membrane  of  the  rectum  remains  unaltered,  and  no  thick- 
ening, induration,  or  strictures  can  be  detected.  The  diagnosis  is 
rendered  more  clear  if  an  irritable  or  displaced  uterus  be  present, 
evincing  the  probability  of  an  analogous  condition  of  the  rectum. 
Irritable  rectum  must  not  be  confounded  with  a  stricture  of  this 
intestine. 

Cases. — The  remark  may  seem  to  be  unnecessary,  but  we  have 
known  at  least  two  different  patients  who  were  treated  for  several 
months  in  succession  for  permanent  contraction  of  this  bowel,  by 
simple  and  medicated  washes,  by  ointments,  caustics,  and  bougies, 
by  a  distinguished  and  justly  influential  surgeon.  The  occa- 
sional passage  in  these  cases  of  large  scybalous  stools  ought  to 
have  convinced  him  of  the  absence  of  stricture ;  even  if  from 
spasm  of  the  internal  sphincter,  or  of  the  rectum  generally,  or 
from  any  other  cause,  he  could  not  pass  his  bougies  beyond  a 
limited  distance. 

In  another  case,  a  patient,  who  fell  under  our  own  care  event- 
ually, and  who  declared  she  would  rather  suffer  martyrdom  than 


208      PROGRESS    AND    RESULTS    OF    IRRITABLE    UTERUS. 

have  an  evacuation  from  her  bowels,  was  treated  for  some  six 
months  by  a  most  distinguished  physician  for  iissura  ani,  as  he 
thought  naught  else  would  account  for  the  intensity  of  her  agony 
during  an  evacuation  from  her  bowels.  A  more  careful  exami- 
nation  of  the  circumference  of  the  anus,  of  the  seat  of  the  pain, 
and  of  the  position  and  condition  of  the  uterus,  would  have  dis- 
abused him  of  his  idea.  This  patient,  who  had  been  a  great 
sufferer  for  upwards  of  three  years,  perfectly  recovered  subse- 
qiiently,  by  a  recourse  to  remedies  for  a  most  sensitive,  and  par- 
tially retroverted  uterus. 

Several  patients  have  applied  to  the  author  for'  relief  from 
what  they  imagined  to  be  "inward  piles  ;"  the  sensations  of  ful- 
ness, weight,  pressure,  and  obstruction,  were  so  great  that  they 
deemed  no  other  explanation  than  the  existence  of  h^eraorrhoids 
satisfactor}?-,  and  as  no  swelling  was  present  at  the  anus,  tumors 
were  supposed  to  exist  within  the  rectum.  Such  cases,  we  found, 
were  generally  mild  examples  of  irritable  rectum,  dependent 
entirely  upon  the  pressure  of  a  displaced  uterus  on  the  lower 
portion  of  this  intestine. 

Hsemorrhoidal  tumors,  ascarides,  fistula  in  ano,  and  other  ana- 
logous complaints,  can  easily  be  recognized  as  complicating  and 
aggravating  the  symptoms  of  irritable  rectum. 


IRRITABLE  VULVA  AND  VAGINA  (VAGINISxMUS). 

Irritable  Vulva  and  Vagina  not  unfrequently  exist,  and  are  so 
often  conjoined  that  they  must  be  considered  together ;  although 
the  predominance  of  the  symptoms  at  the  vulva  is  generally  so 
decided  that  the  state  of  the  vagina  is  often  unheeded.  This  is 
in  accordance  with  the  normal  physiological  character  of  these 
tissues ;  the  most  excitable  or  sensitive  surfaces  are  naturally  the 
vestibulum  and  the  orifice  of  the  vagina,  especially  that  portion 
embracing  the  orifice  and  the  vaginal  surface  of  the  urethra. 

In  a  morbid  irritable  state  of  these  parts,  the  suft'eriugs  are 
often  extreme.  In  bad  cases,  the  patient  has  hardly  any  interval 
of  rest.  The  local  irritation,  sometimes  characterized  by  the 
words  pain,  heat,  burning,  pressure,  fulness,  etc.,  is  truly  inde- 
scribable, and  of  a  peculiar,  distressing,  nervous  character.  It 
radiates  to  the  vagina,  uterus,  rectum,  and  sacral  nerves,  and  thus 


IRRITABLE    VULVA    AND    VAGIXA.  209 

to  the  whole  cerebro-spinal  system,  exciting  the  most  terrible 
mental,  moral,  and  physical  disturbances.  Nymphomania,  with 
all  its  horrors  and  ungovernable  propensities,  may  thus  arise 
even  in  the  most  refined  and  virtuous  woman.  These  are,  how- 
ever, comparatively  rare  cases;  but  even  ordinarily,  the  local 
sensations  are  very  distressing.  Thus  the  least  touch,  even  with 
a  soft  brush  or  sponge,  is  dreaded.  Coitus  is  almost  impossible.^ 
Tactile  examinations,  although  made  in  the  most  gentle  manner, 
are  very  painful ;  so  also  the  effort  to  stand,  walk,  or  strain. 
The  sitting  posture  is  often  avoided.  Micturition  is  painful,  yet 
there  is  often  a  constant  inclination  to  pass  the  urine,  when  the 
orifice  of  the  urethra  is  the  chief  seat  of  the  complaint.  The 
attempt  is  accompanied  with  great  and  prolonged  straining,  and 
the  passage  of  urine  affords  but  a  momentary  relief,  as  the  desire 
returns  in  full  force  almost  immediately.  The  sphincters  of  the 
urethra,,  orifice  of  the  vagina,  and  of  the  anus,  with  the  perineal 
muscles,  are  often  irregularly  and  spasmodically  excited,  thus 
greatly  aggravating  the  sufferings  of  the  patient.  The  same  sen- 
sitiveness, in  a  minor  degree,  affects  the  whole  canal  of  the 
vagina,  so  that  •  examinations  of  this  tube  are  distressing  and 
painful.  Sometimes  we  have  felt  the  whole  vagina  powerfully 
and  spasmodically  contracted  around  the  finger  or  pessary. 

All  these  severe  symptoms  frequently  appear  without  any  evi- 
dences of  inflammatory  action,  even  when  the  disease  is  chronic; 
and  after  months'  and  years'  duration,  no  preternatural  secre- 
tions, no  thickening,  or  other  alteration  of  tissue,  can  be  detected. 
Sometimes  even  no  redness  exists:  but  of  course  in  such  vascular 
and  erectile,  as  well  as  sensitive  tissues,  congestions  not  unfre- 
quently  occur;  the  membranes  become  unusually  red,  and  a 
tumid  or  partial  erectile  state  of  the  clitoris,  nymphje,  and  vulva 
may  ensue.  This  congestion  is  more  frequently  noticed  at  the 
orifice  and  in  the  caruncle  and  dense  tissue  of  the  urethra,  which 
thus  becomes  tumid,  sometimes  hypertrophied,  projecting  more 
than  is  natural,  and  is  exquisitely  sensitive.  This  development 
of  the  under  surface  of  the  urethra  has  been  often  noticed  as  "  a 
tumor,"  a  new  growth  or  production,  but  this  must  certainly  be 

'  Dr.  Marion  Sims  details  an  extraordinary  case  of  a  lady,  who,  after  being 
married  twenty-five  years,  remained  in  a  virgin  condition,  owing  to  this  hyperses- 
thesia  of  the  vulva,  etc.  When  in  a  state  of  antesthesia,  tactile  examination 
revealed  a  perfectly  natural  condition  of  the  tissues. 

14 


210      PROGEESS    AND    RESULTS    OF    IRRITABLE    UTERUS. 

very  rare ;  at  least  we  have  seldom  met  with  a  case,  where  there 
was  that  degree  of  hardness  which  could  be  regarded  as  the  result 
of  inflammatory  action,  or  where  any  adventitious  growth  was 
present.  In  nearly  all  the  cases  that  we  have  examined,  there  has 
been  a  simple  congestion  or  hypertrophy  of  the  extremity  of  the 
urethra,  disappearing  when  the  nervous  irritation  ceased. 

In  these  irritations  of  the  vulva,  there  is  seldom  any  increased 
secretion ;  the  membranes  are  often  more  dry  and  smooth  than 
natural ;  the  occurrence  of  secretion  is  productive  of  relief. 

Many  patients  are  tormented  for  a  longer  or  shorter  period 
(usually  transitory)  with  a  distressing  itching  of  the  vulva.  This 
has  been  designated  unfortunately  as  a  separate  disease,  under 
the  term  '■'■  jjruritus  vulvse^  It  is  often  so  severe  as  greatly  to 
disturb  the  brain,  producing  even  delirium  and  spasms.  It  occurs 
in  pregnancy,  in  diseases  of  the  uterus,  with  or  without  leucor- 
rhoea,  as  well  as  in  irritations  of  the  vulva.  This  often  exists,  at 
least,  in  a  chronic  state,  without  inflammation.  We  have  known 
it  last  for  years,  yet  the  membranes  remained  pallid  and  free  from 
the  evidences  of  inflammation.  This  irritation  is  generally  of  a 
purely  nervous  character,  often  accompanied  with  active  conges- 
tion of  the  bloodvessels,  especially  when  chronic.  In  the  acute 
form,  it  is  more  frequently  perhaps  inflammatory,  a  symptom  of 
vulvitis  or  vaginitis,  or  both.  Then  the  membrane  is  dry,  tense, 
smooth,  more  red  than  natural,  sometimes  with  albuminoid  exuda- 
tions, as  in  aphthous  affections,  perhaps  sometimes  with  super- 
ficial ulcerations,  as  reported  by  some  few  authors.  This  inflam- 
mation is  always  superficial,  a  species  of  erythema,  is  generally 
transitory,  and  leaves  the  tissues  sound  but  perhaps  still  more 
sensitive.  The  itching  sometimes  vanishes  with  the  inflamma- 
tion. 

The  causes  of  irritable  vulva  and  vagina,  both  predisposing  and 
exciting,  are  usually  identical  with  those  of  uterine  irritation. 
They  are  often  conjoined,  the  former  in  many  instances  seeming. 
to  be  merely  the  sequela  of  the  latter.  Nevertheless,  the  irrita- 
tion of  the  uterus  is  often  very  great,  while  that  of  the  vulva  is 
trifling,  and  the  reverse  is  also  true.  Irritable  vagina  may  not 
only  result  from  uterine  irritations,  but  be  consequential  on  in- 
flammation of  the  vulva  and  vagina ;  the  inflammation  having 
been  removed,  the  sensitiveness  may  continue.  It  is,  perhaps, 
sometimes  the  result  of  continence  in  girls  of  a  nervous  tempera- 


IRRITABLE    BLADDER    AND    URETHRA.  211 

ment,  and  of  warm  erotic  passions,  combined,  perhaps,  with  secret 
self-excitement,  being  less  frequent  in  married  women.  On  the 
contrary,  it  is,  also,  the  consequence  of  "  Nimia  Venus,"  particu- 
larly in  young  married  women  who  remain  sterile.  Mechanical 
irritation,  stimulating  washes  or  acrid  discharges  from  the  uterus, 
the  presence  of  ascarides  in  the  vagina,  sometimes,  also,  of  foreign 
bodies,  as  of  pessaries,  are  all  said  occasionally  to  excite  the 
symptoms  of  irritable  vulva  and  vagina.  By  far  the  most  fre- 
quent cause  is  uterine  displacement ;  which,  besides  rendering  the 
uterus  sensitive,  directly  and  indirectly  affects  the  vagina,  partly 
by  the  sympathetic  extension  of  the  symptoms  of  nervous  irrita- 
tion from  the  womb,  and  partly  by  the  pressure,  dragging,  and 
similar  sources  of  irritation  from  a  prolapsed,  retroverted,  or  re- 
troflexed  uterus. 

The  diagnosis  is  by  no  means  easily  made  out  in  all  cases,  be- 
tween it  and  vaginitis,  as  the  symptoms  are  very  similar.  In 
irritable  vulva  and  vagina,  however,  especially  in  the  chronic 
forms,  there  is  an  absence  of  the  turgescence  and  fulness  of  the 
mucous  membrane,  of  the  lymphatic  and  purulent  secretions,  of 
the  thickening,  induration,  and  contraction  of  the  passages.  In 
many  cases  of  months  and  years  of  suffering,  no  purulent  evacua- 
tions have  ensued,  nor  any  alteration  of  the  tissues,  which  are  as 
delicate  and  as  pliable  as  in  their  normal  state,  and  after  recovery 
no  vestige  of  previous  disorder  remains.  Nevertheless,  the  line 
of  demarcation  between  the  two  affections  cannot  be  accurately 
drawn.  Here,  as  elsewhere,  the  two  are  often  conjoined  ;  the  pain 
of  itself  would  almost  indicate  this,  being  much  more  intense  than 
the  same  amount  of  inflammation  would  usually  excite.  In  other 
cases,  an  irritable  condition  follows  what  was  at  first  mere  inflam- 
mation. 


IRRITABLE  BLADDER  AND  URETHRA. 

These  are  among  the  most  distressing  varieties  of  nervous  irri- 
tation. In  bad  cases  the  sufferings  are  horrible ;  there  is  not 
only  the  usual  amount  of  pain,  heat,  burning,  pressure,  fulness 
and  weight ;  but  there  is  the  ever  existing  tormenting  desire  to 
urinate,  every  five  or  ten  minutes,  or  even  constantly  for  hours 
at  a  time.     The  patient  feels  as  if  the  attempt  to  pass  her  urine 


212      PROGRESS    AND    RESULTS    OF    IRRITABLE    UTERUS. 

must  be  repeated  every  minute,  and  persists  in  it  for  half  an  hour, 
or  even  longer ;  yet,  but  a  few  drops  of  urine  are  evacuated  after 
the  most  powerful  bearing-down  efforts  and  agonizing  pain.  This 
is  often  accompanied  with  spasms  of  the  bladder,  urethra,  vagina, 
rectum,  and  the  levatores  ani  muscles ;  all  aggravating  the  suffer- 
ings of  the  unfortunate  patient.  The  consequent  loss  of  sleep,  of 
fresh  air,  of  exercise,  and  often  the  diminution  or  loss  of  the  appe- 
tite, tend  still  more  to  cause  the  exhaustion  of  the  patient,  and  the 
increase  of  her  mental  and  corporeal  sufferings. 

Cases. — One  patient  had  abandoned  her  bed  altogether,  saying 
it  was  useless  to  lie  down,  as  every  few  moments  the  irritation 
of  her  bladder  would  force  her  to  rise. 

In  another,  the  attacks  came  on  in  paroxysms  of  neuralgic 
and  spasmodic  irritation,  resembling  "  a  fit  of  the  stone."  She 
found  most  relief  in  sitting  upon  the  floor,  with  her  foot  bent 
under  her,  so  that  the  heel  pressed  firmly  against  the  vulva.  The 
bladder  was  several  times  carefully  examined  by  the  sound,  but 
no  calculus  could  be  detected.  She  perfectly  recovered,  under 
the  treatment  hereafter  to  be  indicated. 

In  a  case  of  a  young  unmarried  lady,  where  this  dysuria  had 
existed  for  years,  a  retention  of  urine  occurred,  apparently  from 
spasm  of  the  urethra,  and  for  three  months  rendered  the  use  of  a 
catheter  necessary  two  or  three  times  a  day.  The  inclination  to 
urinate  was  less  urgent  and  less  frequent  during  the  existence  of 
this  retention  than  it  had  been  before. 

In  another,  the  dysuria  for  weeks  would  be  very  distressing, 
and  accompanied  by  a  pulsating  distressing  pain,  or  by  a  vibrat- 
ing "  or  strumming"  sensation,  productive  of  much  nervous  dis- 
tress; then  the  bladder  would  be  comparatively  comfortable,  while 
the  pulsatile  distress  would  be  translated  to  the  rectum,  sometimes 
to  the  extremities,  or  even  to  the  upper  part  of  the  neck,  and  to 
the  face. 

Every  degree  of  suffering  from  the  bladder,  may  be  met  with, 
from  a  more  frequent  desire  to  urinate,  to  the  severe  sufferings 
above  described,  which  are,  however,  comparatively  rare.  Some 
patients  complain  of  pain  during  the  flow  of  the  urine,  in  others,  it 
is  felt  immediately  after  its  evacuation,  in  all,  the  inclination  to 
micturate  soon  returns.  With  all  their  intense  sufferings,  in  very 
few  cases  have  we  been  able  to  detect  any  signs  of  positive  inflam- 
mation, excepting,  always,  that  of  heat,  pain,  and  strangury.     The 


IRRITABLE  BLADDER  AND  URETHRA.       213 

urine  has  been  perfectly  normal  in  its  physical  aspects,  and  its  che- 
mical constituents.  On  standing,  no  mucoid  or  lateritious  deposits, 
and  no  appearance  of  pus  are  exhibited.  There  is  no  evidence  of 
swelling,  or  alteration  of  tissue  in  the  urethra  or  bladder,  no  sym- 
pathetic affections  of  the  kidney,  and  no  febrile  excitement.  The 
relief  of  the  patient  is  sometimes  sudden,  complete  and  perma- 
nent ;  and  even  when  it  continues  more  or  less  for  years,  the  tis- 
sues and  the  secretions  remain  in  their  normal  condition.  In  some 
cases,  we  have  seen  some  small  portions  of  blood  forced  out  of  the 
urethra,  apparently  from  the  violent  straining ;  but  otherwise 
there  was  no  change,  and  this  took  place  only  occasionally. 

Irritable  bladder  may,  however,  be  the  result  of  cystitis,  or  be 
accompanied  by  inflammation,  the  two  complaints  coexisting. 
This  is  true,  especially  in  chronic  cases,  where  the  disease  is 
caused  by  mal-conditions  of  the  urine,  by  gravel,  by  calculus,  or 
other  foreign  substance  in  the  bladder ;  for  even  sufferings  from 
stone  in  the  bladder  are  essentially  neuralgic  and  spasmodic,  and 
not  inflammatory.  Yet,  in  such  cases,  there  is  often  inflamma- 
tion, sometimes  with  purulent  discharges,  and  even  thickening 
of  the  coats  of  the  bladder.  The  paroxysmal  attacks,  known  by 
the  expression  "  fit  of  the  stone,"  are  not  those  of  pure  inflamma- 
tion. Their  dependence  on  the  nervous  and  muscular  tissue  is 
shown  by  their  paroxysmal  character  and  by  the  facts  that  they 
are  neither  accompanied  nor  followed  by  any  increase  of  the  puru- 
lent discharge;  that  they  often  occur  when  there  are  no  pus  glo- 
bules to  be  found  in  the  urine,  and  when  the  secretion  is  perfectly 
natural.  Besides,  although  the  agony  is  intense,  no  febrile  symp- 
toms follow.  The  surgeon  will  also  testify  that  immediatel}^  on 
the  exit  of  the  calculus  per  urethram,  or  by  the  wound  inflicted 
by  the  lithotomist,  the  pain  ceases,  although  days  and  even  weeks 
may  elapse  before  the  inflammation  of  the  bladder  has  vanished. 
All  of  which  is  fully  confirmed  by  the  fact  that  these  severe 
symptoms  of  stone  in  the  bladder  often  exist  where  no  stone  is  to 
be  found,  and  where  no  phlogosis  can  be  detected.  The  terrible 
pain  excited  by  a  calculus  passing  along  a  ureter  is  another  ex- 
ample of  nervous,  not  organic  or  inflammatory  irritation. 

A  similar  analysis  might  be  given  of  the  cystic  irritation, 
arising  from  an  acrid  condition  of  the  urine.  The  dysuria,  the 
strangury,  the  spasms,  and  the  straining  or  bearing-down  efforts 
in  such  cases,  may  and  often  do  exist  without  any  cystitis.     The 


214      PROGRESS    AXU    RESULTS    OF    IRRITABLE    UTERUS, 

urine  is  merely  tlie  irritant  or  exciting  cause  of  the  nervous 
irritation.  Although  these  acrid  secretions  from  the  kidneys  are 
attended  with  inflammation ;  yet,  generally,  the  character  of  the 
irritation,  as  far  as  the  bladder  is  concerned,  is  neuralgic.  The 
cause  is  the  state  of  the  urine,  arising  from  a  morbid  condition  of 
the  circulating  fluids,  of  the  chylopoietic  viscera  or  of  the  kidneys. 

The  causes  of  irritable  bladder  are  generally  similar  to  those 
of  irritable  vagina.  Our  experience,  as  elucidated  by  the  results 
of  treatment,  indicates  that  in  a  very  large  proportion  of  the  cases, 
displacements  of  the  uterus,  also  hypertrophy,  pregnancy,  and 
other  enlargements  of  this  organ,  are  the  original  and  exciting 
causes.  They  operate  by  direct  pressure  on  the  bladder,  or  else 
by  the  dragging  to  which  this  viscus  is  exposed  in  some  cases 
of  displacement  of  the  uterus,  particularly  in  retroversion  and 
procidentia. 

Irritable  bladder  may  arise  also  from  cold,  from  rheumatic, 
gouty,  or  other  inflammatory  states  (the  irritability  remaining 
after  the  inflammation  has  disappeared),  also  from  acrid  urine,  the 
use  of  cantharides,  of  turpentine,  as  internal  or  external  reme- 
dies; from  gravel,  calculus,  or  other  foreign  substances  in  the 
bladder ;  from  mere  sympathy  with  diseases  of  the  vulva,  rectum, 
or  uterus.  Possibly,  it  may  be  sometimes  the  result  of  that  gene- 
ral irritability  of  the  whole  nervous  system,  met  with  in  girls  of 
a  very  nervous  temperament,  whose  physical,  and,  perhaps,  moral 
training  has  been  very  injudicious ;  and  in  whom  almost  every 
tissue  and  organ  is  preternaturally  sensitive.  Irritable  bladder  is 
also  the  result,  not  unfrequently,  of  abortions  and  labors. 

The  diafj7iosis  is,  of  course,  in  some  respects,  very  easy.  But 
great  attention  must  be  paid  to  the  history  of  any  individual  case, 
to  determine  how  far  it  be  an  original  or  a  secondary  affection, 
and  what  is  the  peculiar  exciting  cause,  and  also  how  far  it  is 
purely  an  example  of  irritable  tissue,  or  complicated  with  inflam- 
matory disturbance.  The  whole  success  of  the  treatment  depends 
upon  an  accurate  investigation  of  these  points. 

It  is,  however,  comparatively  seldom  in  practice  that  the  blad- 
der, vagina,  or  rectum,  are  isolated  in  their  sufferings.  Most  fre- 
quently, in  severe  cases,  all  the  pelvic  viscera  are  involved,  the 
uterus  having  been  the  original  source  of  mischief.  In  very  many 
it  is  the  rectum,  in  others  the  bladder,  in  others,  again,  the  vagina 
which  chiefly  sympathizes  with  the  uterus. 


IRRITATIONS    OF    THE    OVARIES.  215 

IRRITATIONS  AND  ENLARGEMENTS  OF  THE  OVARIES. 

The  question  has  been  starfed  by  some,  how  far  these  symp- 
toms, as  now  detailed,  of  irritable  uterus,  are  referable  to  the 
ovaries^  whether  these  bodies  ever  become  irritable,  and  whether 
their  affections  are  usually  the  cause  of  spinal  and  cerebral  irrita- 
tion. 

Arguments  in  favor  of  this  supposition  are  drawn  from  the 
physiological  as  well  as  the  pathological  condition  of  the  ovaries. 
It  has  always  been  conceded  that  a  healthy  condition  of  the  ova- 
ries is  necessary  for  menstruation,  and  perhaps  for  most  of  the 
sexual  propensities  and  characteristics  of  women.  The  modern 
theory  of  menstruation  also  presupposes  a  maturation  of  a  vesicle 
accompanied  by  great  engorgement,  and  followed,  sooner  or  later, 
by  a  rupture  of  the  ovisac,  and  by  oviposition.  Hence,  these 
changes  of  the  ovaries,  purely  physiological,  are  the  cause  of  the 
uterine  excitement,  and  the  engorgement  and  the  subsequent  san 
guineous  discharge.  Hence,  when  there  is  any  unusual  or  morbid 
excitement  of  the  ovaries,  ^.  e.,  when  the  ovaries  are  irritable, 
there  will  be  not  only  a  greater  degree  of  congestion  of  these 
organs,  but  also  a  corresponding  excitement  and  congestion  of  the 
uterine  system.  Hence,  also,  an  irritable  ovary  is  doubtless  a 
cause  of  irritable  uterus. 

M.  Negrier  has  termed  this  hypersesthesia  of  the  ovary  "Oyan'e," 
and  he.  Dr.  Laycock,  and  others  have  referred  all  the  phenomena 
of  hysteria  to  this  source,  from  which,  as  a  focus,  radiate  irritations 
to  the  ganglionic  and  cerebral  symptoms ;  and,  they  contend,  with- 
out any  inflammation  or  organic  lesion  of  the  ovary.  Numerous 
facts  seem  to  support  this  idea,  but  we  must  deem  it  a  superficial 
one.  The  cause  lies  deeper  in  those  inscrutable  circumstances 
which  contribute  to  the  whole  development  of  the  phenomena  of 
puberty.  These  phenomena  are  by  no  means  confined  to  the 
ovaries  in  women,  or  to  the  testicles  in  men ;  these  organs  are 
themselves  developed,  pari  passu,  with  the  other  tissues  and  organs 
of  the  economy ;  they  do  not  precede,  but  merely  accompany  the 
changes  which  are  observed  in  other  portions  of  the  genitalia  and 
the  various  tissues  and  organs  of  the  body.  Although  hysteria 
often  depends  upon  ovarian  excitement,  yet  whence  this  excite- 
ment ?     Is  it  not  to  be  traced  to  previous  nervous  disturbance, 


216      PROGRESS    AND    RESULTS    OF    IRRITABLE    UTERUS. 

and  this  again  to  passions  or  affections  of  the  mind,  or  some  dis- 
tant source  of  irritation,  in  which  the  ovaries  are  not  involved. 
Hysteria  also  is  often  excited  in  women  by  indigestion,  by  strong 
moral  or  mental  impressions,  where  there  is  no  primary  irritation 
of  the  sexual  organs.  Experience,  also,  abundantly  shows,  cer- 
tainly in  our  own  practice,  that  direct  impressions  upon  the  uterus 
will  excite  hysteric  spasms  and  convulsions.  Moreover,  hysteria 
occasionally  exists  in  the  male  subject,  and  in  some  cases  from 
debility  and  exhaustion  in  both  sexes. 

We  should  conclude,  therefore,  that  these  nervous  excitements 
called  "hysteria"  have  a  common  origin  in  the  peculiarities  of 
the  cerebro-spinal  nervous  system,  not  to  be  apprehended  or  ex- 
plained, and  that  the  varjnng  condition  of  the  ovaries,  the  uterus, 
the  vulva,  or  even  of  the  stomach,  bowels,  brain,  etc.,  are  but 
accessory  or  exciting  causes. 

The  diagnosis  must  necessarily  be  extremely  difficult  in  all 
ovarian  diseases,  except  where  the  ovaries  are  greatly  enlarged. 
Their  natural  position  behind  the  broad  ligaments  prevents  any 
accurate  examination  from  being  made  either  externally  or  inter- 
nally. By  the  finger  per  vaginam,  nothing  can  be  felt:  per  rec- 
tum, the  same  observation  may,  we  think,  be  made ;  although  it 
has  been  asserted  that  the  finger  can  so  distend  the  anterior  wall 
of  the  rectum,  and  be  bent  up  behind  the  uterus  and  broad  liga- 
ment, as  to  reach  the  diseased  ovary.  In  the  case  of  an  enlarged 
or  displaced  ovary,  this  is  practicable ;  but  it  seems  to  us,  that, 
in  other  cases,  it  is  impossible.  The  finger  is  far  too  short  to 
reach  a  small  body  in  the  posterior  part  of  the  pelvis,  and  high 
above  the  rectum.  Besides,  this  intestine  is  so  well  supplied  with 
strong  muscular  fasciculi,  as  not  only  to  afford  a  mechanical  re- 
sistance, but  also  a  vital  spasmodic  opposition.  The  mere  attempt 
is  accompanied  so  universally  by  intense  pain,  as  to  defy  any  per- 
sistent trials,  especially  in  cases  of  an  irritable  or  inflamed  condi- 
tion of  the  tissues.  Certainly,  also,  if  any  body  be  distinctly 
recognized,  it  would  be  very  difficult,  if  not  impossible,  to  deter- 
mine Avhether  it  were  an  ovary ;  a  portion  of  feculent  matter  in 
an  intestine ;  a  tumor  of  the  uterus ;  an  enlarged  lymphatic  or 
mesenteric  gland ;  a  tumor  developed  in  the  broad  ligaments  or 
in  the  peritoneum  from  inflammation,  efi'usion  of  blood,  or  from 
any  organic  disease ;  an  osseous  growth ;  or  even,  perhaps,  for 
similar  mistakes  have  been  made,  whether  the  supposed  ovary  was 


IRRITATIONS    OF    THE    OVARIES.  217 

not  the  fundus  of  a  retroflexed  uterus,  tlie  cervix  uteri  being  still 
iyi  situ  naturali. 

In  post-mortem  examinations  of  individuals  dead  from  other 
diseases,  unmistakable  evidences  have  often  been  found  that  the 
ovaries  had  been  inflamed ;  such  as  adhesions  to  other  parts,  and 
alterations  in  their  structure.  The  practical  difficulty  is,  how- 
ever, to  say  when  this  inflammation  occurred,  or  what  are  its 
positive  indications  during  life.  The  fact  that  the  knife  does  re- 
veal, after  death,  that  there  has  been  such  a  disease  as  inflamma- 
tion of  the  ovaries,  does  not  prove  that,  in  any  particular  case  of 
morbid  irritation  of  the  pelvic  viscera,  ovaritis  must  be  present. 
So  general  a  deduction,  surely,  would  be  an  absurdity. 

The  fact  that  pain  in  the  region  of  an  ovary  is  very  common, 
constant,  and  sometimes  very  severe,  is  no  positive  proof  of  the 
existence  of  ovaritis.  Because,  in  the  chronic  cases  to  which  we 
now  allude,  the  pain  is  much  more  severe  than  in  chronic  inflam- 
mations of  these  tissues.  It  is,  indeed,  often  intense,  comes  on  in 
paroxysms,  is  seldom  aggravated,  but  is  often  moderated,  by  firm 
pressure  from  a  hand,  a  bandage,  or  abdominal  supporters  con- 
stantly worn.  It  extends  to  the  groin,  to  the  front  and  inside  of 
the  thigh,  and  sometimes  is  evidently  connected  with  pain  in  the 
back.  It  is  unaccompanied  by  any  enlargement,  which  can  be 
discovered  by  an  external  or  internal  examination.  The  patient 
has  no  fever  (inflammatory,  or  hectic),  is  often  not  emaciated  or 
anaemic,  and  frequently,  as  regards  her  organic  life,  is  perfectly 
well,  with  plenty  of  rich  blood,  strength,  and  physical  develop- 
ment. The  pain  may  be  very  persistent  for  days,  months,  and 
years,  without  any  local  or  general  change  ensuing.  In  many 
patients,  brought  to  our  care,  the  antiphlogistic  treatment  had  been 
perseveringly  and  repeatedly  resorted  to,  in  all  its  modifications, 
by  rest,  leeches,  fomentations,  by  blisters,  and  other  revulsives,  and 
had  entirely  failed  to  afibrd  any  permanent  relief;  but  had  rather 
aggravated  the  sufferings,  by  debilitating  the  patient,  and  thus 
rendering  her  nerves  more  sensitive,  and  her  sufferings  greater. 
In  such  cases,  relief  from  this  obstinate  pain  has  been  afforded 
by  remedies  addressed  to  the  uterus  as  an  irritable  organ.  In 
proportion  as  the  uterine  symptoms  were  moderated  or  aggra- 
vated, this  pain  "in  the  side,"  as  the  patients  call  it,  just  above 
Poupart's  ligament,  was  lessened  or  increased;    and  when  the 


218      PROGRESS    AND    RESULTS    OF    IRRITABLE    UTERUS. 

patient  was  entirely  relieved  of  uterine  affection,  this  pain  van- 
ished, without  any  attention  being  paid  to  the  ovary. 

The  legitimate  inference,  therefore,  is,  that  this  pain  is  very 
often  dependent  not  on  the  ovary,  but,  directly  or  indirectly,  upon 
the  uterus.  The  probability  is,  that  it  is  connected  with  those, 
partly  muscular,  cords,  or  "  round  ligaments"  of  the  uterus,  in 
their  course  towards  the  internal  abdominal  ring,  or  along  the 
abdominal  canal. 

Although,  therefore,  chronic  inflammations  of  the  ovary  or 
ovaries  do  sometimes  occur,  and  although  they  may  sometimes 
be  coexistent  with  an  irritable  uterus,  yet  the  diagnosis  must  be 
very  obscure.  In  practice,  such  inflammations  can  hardly  be 
recognized,  and  are,  therefore,  necessarily  disregarded.  Not  so, 
however,  in  cases  of  enlarged  ovary,  whether  such  enlargement 
has  been  the  result  of  inflammation  merely,  or  has  arisen  from 
those  morbid  depositions  in  the  stroma  or  vesicles  of  these 
organs,  which  are  known  familiarly  by  the  name  of  tumors  of 
the  ovaries.  Our  observation  has  been  that  such  tumors  are 
generally  not  sensitive,  they  often  manifest  no  irritability ;  and 
pressure  on  them  internally  or  externally  can  frequently  be  made 
with  impunity.  Nevertheless  such  ovarian  tumors,  when  they 
are  not  very  large  and  remain  in  the  pelvis,  are  often  productive 
of  all  the  symptoms  of  a  displaced  and  irritable  uterus.  This 
results,  doubtless,  from  several  causes.  For  instance,  it  occa- 
sionally happens  that,  owing  to  the  displacements  of  such  ovarian 
tumors  in  the  pelvis,  they  become  themselves  morbidly  sensitive; 
eases  of  which  will  be  mentioned  under  the  head  of  displaced 
ovaries.  Another  cause  is  the  pressure  made  by  the  enlarged 
ovary  against  the  uterus,  which,  besides  rendering  it  sensitive 
and  painful,  may  produce,  in  many  instances,  a  displacement  of 
the  uterus,  laterally,  to  the  opposite  side  of  the  pelvis  or  directly 
downwards,  as  in  prolapsus  uteri,  with  or  without  flexion,  and 
sometimes  anteriorly,  so  that  the  uterus  is  pressed  against  the 
bones  of  the  pubis. 

Case. — We  are  now  attending  a  lady  in  whom  a  large  tumor, 
apparently  ovarian,  occupies  the  posterior  portion  of  the  cavity 
of  the  pelvis  chiefly  on  the  right  side.  It  is  so  large  that  the 
uterus,  still  of  its  normal  size,  is  pushed  against  the  pubis  and 
elevated  so  that  the  outline  of  the  organ  can  be  distinctly  traced 
through  the  parietes  of  the  abdomen  in  the  hypogastrium,  while 


IRRITATIONS    OF    LYMPHATIC    GLANDS.  219 

tlie  neck  of  the  uterus  can  be  felt,  bj  a  vaginal  examination,  near 
and  behind  ihe  pubis.  In  this  case,  as  in  many  others  which  we 
have  examined,  pressure  on  this  displaced  uterus  gives  pain,  but 
pressure  on  the  ovarian  tumor  excites  no  uneasiness. 

There  is  still  another  cause,  which  should  be  mentioned,  of 
spinal  irritation  from  an  enlarged  and  displaced  ovary  in  the 
cavity  of  the  pelvis,  namely,  the  pressure  made  on  the  nerves  of 
the  pelvis,  especially  the  obtijrator  and  the  sacral  nerves  and  the 
sciatic  plexus.  Of  the  many  cases  of  displaced  ovary  that  have 
come  under  our  care,  some  have  experienced  but  slight  inconve- 
nience from  this  cause,  while  in  others  the  results  of  the  pressure 
were  very  severe. 

Cases. — A  physician,  some  years  ago,  from  the  South  requested 
us  to  examine  his  wife,  as  he  suspected  from  her  complaints  there 
was  a  scirrhus  of  the  uterus.  The  uterus  was  found  in  a  normal 
state,  though  slightly  prolapsed,  and  an  ovarian  tumor  of  the 
size  of  a  goose's  egg  on  the  right  side  of  the  pelvis.  A  pessary 
relieved  all  her  uneasiness  in  a  very  short  time.  Several  years 
afterwards  we  examined  this  case,  and  found  the  tumor  had 
greatly  diminished  in  size.     She  still  enjoys  very  good  health. 

In  another  lady,  the  symptoms  of  cerebral  and  spinal  irritation 
had  been  intense,  with  great  mental  and  physical  exhaustion,  for 
some  twelve  years.  To  our  surprise,  on  examination,  the  uterus 
although  hypertrophied  and  somewhat  displaced  laterally  to  the 
left,  was  by  no  means  irritable.  An  enlarged  ovary  was  found 
pressed  down  in  the  right  sacro-sciatic  notch.  In  proportion  as 
mechanical  supports  were  successful  in  elevating  the  tumor,  the 
patient's  physical  and  mental  symptoms  were  relieved.  She  can- 
not, however,  be  at  all  comfortable  unless  the  mechanical  support 
is  properly  adjusted  with  reference  to  this  tumor. 

The  subject  of  displaced  ovaries  and  their  consequences  will  be 
resumed  hereafter  under  another  division  of  this  work,  namely, 
that  of  displacements  of  the  uterus. 


IRRITATIONS  OF  LYMPHATIC  GLANDS. 

"We  have  seen  a  few  cases  of  excessive  sensitiveness  of  small 
bodies,  probably  lymphatic  glands  in  the  pelvis. 

Case. — A  fine  healthy  young  married  woman  came  under  our 


220      PKOGEESS    AND    RESULTS    OF    IRRITABLE    UTERUS. 

care  from  Virginia.  She  was  a  ladj  of  reat  sprightliness  and 
activity,  but,  from  excessive  suffering  for  more  tlian  a  year  after 
tlie  birth  of  her  child,  was  constantly  confined  to  her  bed.  All 
ordinary  remedies  failing,  she  was  in  the  daily  habit  of  taking 
laudanum  to  procure  sleep  and  relief  from  pain.  Her  health  was 
otherwise  very  good.  A  vaginal  examination  revealed  a  uterus 
somewhat  hypertrophied  and  completely  retroverted.  After  the 
retroversion  had  been  relieved,  the  patient  was  comparatively 
comfortable,  and  abandoned  her  opiates.  She  made  no  complaints 
when  quiet,  but  on  attempting  to  walk  the  terrible  pain  in  the 
back  would  return,  yet  without  any  renewal  of  the  displacement. 
On  a  further  and  more  minute  examination,  we  detected  a  small 
flattened  body,  about  an  inch  in  diameter,  lying  on  the  right  side 
of  the  rectum  low  down  in  the  cavity  of  the  sacrum.  It  was 
loosely  attached,  quite  movable,  and  in  many  respects  similar  to 
a  lymphatic  gland,  but  excessively  sensitive.  The  patient  com- 
plained very  much  whenever  it  was  merely  touched.  It  was  now 
evident  that  the  superior  margin  of  the  pessary  which  supported 
the  uterus  in  situ,  pressed  upon  this  irritable  body,  and  was  the 
cause  of  her  sufferings.  After  many  experiments,  the  uterus  was 
supported  by  an  instrument  which  was  made  of  such  a  form  as 
to  elevate  this  sensitive  gland  bej^ond  any  sources  of  irritation. 
Then  the  patient  was  able  to  walk  with  impunity.  She  returned 
home  and  continued  well  until  the  birth  of  another  child,  when 
the  same  trouble  returned,  but  with  less  intensity.  Similar  relief 
was  again  afforded  on  her  return  to  Philadelphia.  The  birth  of 
a  third  child  was  followed  by  a  similar  trouble.  We  then  found 
the  gland  was  softer,  still  movable,  and  much  less  sensitive.  The 
relief  given  as  before,  by  the  pessary,  has  from  late  accounts  con- 
tinued, and  the  patient  is  still  very  well. 

In  another  case,  from  Louisiana,  we  detected  a  very  similar 
swelling  in  the  left  side  of  the  pelvis,  giving  rise  to  the  same 
suft'ering  and  the  same  difficulties  in  the  treatment.  The  patient 
was  married,  but  had  never  conceived.  She  also  was  able  to 
wear  a  supporter  internally  for  four  years  without  irritation  and 
with  relief.  That  this  one  especially  was  not  a  displaced  ovary, 
although  connected  with  the  broad  ligament,  we  inferred,  from 
its  being  more  fiat  and  more  of  the  square  form  than  the  ovary. 
It  was  lower  down  and  more  anterior,  and  could,  therefore,  be 
more  distinctly  felt ;  although  movable,  it  was  located  too  near 


lERITATlONS    OF    THE    PELVIC    NERVES.  221 

tlie  plane  of  the  ischium  and  its  movements  were  too  circum- 
scribed to  regard  it  as  an  ovary  floating  on  the  broad  ligaments 
among  the  intestines. 

In  neither  of  these  cases  was  there  any  symptom  of  inflamma- 
tory action,  excepting,  of  course,  excessive  sensitiveness ;  there 
w^ere  no  thickening,  induration,  or  fixation  of  the  tissues,  no  fur- 
ther increase  of  size,  and,  of  course,  no  suppuration.  Indeed,  the 
size  and  density,  as  well  as  the  sensitiveness,  gradually  dimi- 
nished, and  gave  the  patient  no  trouble  whatever  when  the  tumors 
w^ere  so  supported  as  to  keep  them  free  from  irritation ;  and  in 
both  cases  years  elapsed  between  the  first  and  final  examinations. 
They  seemed,  indeed,  to  present  pure  examples  of  an  "  hypertro- 
phied  and  irritable  tissue." 


IRRITATIONS  OF  THE  PELVIC  NERVES. 

The  only  remaining  tissue  of  the  pelvis  which  need  be  men- 
tioned is  the  nervous. 

Continual  reference  has  been  made  in  the  preceding  pages  to 
"  sacral  irritation,"  or,  more  accurately,  to  the  irritation  of  the 
large  sacral  nerves  as  they  emerge  from  the  foramina  on  the  ante- 
rior surface  of  the  sacrum,  and  run  obliquely  and  for  a  short  dis- 
tance in  grooves  on  the  surface  of  the  bone  to  form  the  great 
sacro-sciatic  plexus  on  either  side.  They  are  intimately  asso- 
ciated with  the  lower  hypogastric  and  sacral  ganglia  of  the 
sympathetic  nerve,  and,  of  course,  with  the  whole  nervous  sys- 
tem of  the  uterus  and  its  appendages.  It  necessarily  results, 
therefore,  that,  in  all  cases  of  irritable  uterus,  there  will  be  more 
or  less  morbid  sensitiveness  of  the  sacral  nerves,  as  indicated, 
not  simply  by  pain  in  the  back,  and  in  the  uterus,  but  also  by  the 
neuralgic  pains,  cramps,  spasms,  and  various  morbid  sensations, 
extending  to  the  nates,  and  down  the  lower  extremities,  and  often 
in  an  opposite  direction  to  the  spinal  marrow  and  brain,  causing 
spinal  and  cerebral  irritations  with  their  consequences.  But  this 
sympathetic  irritability  is  greatly  enhanced  by  pressure  on  these 
nerves  themselves,  whether  from  sudden  muscular  effort  of  the 
patient,  from  scybalous  stools,  a  prolapsed  or  retroverted  uterus, 
ovarian  or  other  tumors,  pessaries  or  other  foreign  bodies  in  the 
vagina.     The  effects  of  this  pressure  are  aggravated  by  the  fact, 


222      PROGEESS    AND    RESULTS    OF    IRRITABLE    UTERUS. 

that  tlie  nerves  are  often  compressed  against  the  bone,  exciting 
at  the  moment  severe  darting  neuralgic  pains.  Every  obstetrical 
practitioner  is  perfectly  aware  that  much  of  the  distress  towards 
the  conclusion  of  labor,  especially  the  pains  in  the  back  and 
lower  limbs,  the  tremors  and  cramps  of  the  muscles  arise  from 
the  pressure  of  the  child's  head  on  the  sacral  nerves.  So,  also, 
in  the  unimpregnated  condition,  during  manipulations  with  pes- 
saries in  the  vagina,  frequently  some  of  these  nerves  are  touched, 
giving  rise  to  pains  often  expressed  as  "  darting,"  "  lancinating," 
"toothache-like,"  "  lightning,"  and  by  other  similar  significant 
terms. 

There  is,  therefore,  generated,  in  many  instances,  a  morbid 
sensitiveness  of  the  sacral  nerves,  an  "  irritability,"  which  is 
purely  nervous  and  not  inflammatory.  The  proof  seems  posi- 
tive, for  the  symptoms  disappear  as  soon  as  the  cause  is  removed, 
while  they  continue  for  years  if  the  cause  remain  operative. 
But  even  in  such  cases  no  intimation  of  inflammatory  disturbance 
can  be  discovered,  no  local  alteration  of  tissues,  and  no  injury  to 
the  general  health,  except  what  may  indirectly  result  from  pain 
and  confinement,  and,  perhaps,  it  might  be  added,  from  injudi- 
cious and  unscientific  treatment. 

Similar  observations  may  be  made  of  other  nerves,  especially 
of  the  obturator^  as  it  passes  along  the  sides  of  the  pelvis  to  its 
point  of  egress  at  the  superior  part  of  the  obturator  foramen. 
Pain,  soreness,  numbness,  stifihess,  or  weakness  of  the  adductor 
muscles  of  the  thigh  are,  probably,  dependent  on  irritations  of 
this  nerve,  which  very  soon  becomes  morbidly  sensitive. 

In  a  patient  whom  we  are  now  attending  the  pain  is  chiefly  in 
the  right  iliac  region,  and  down  the  front  of  the  thigh.  When 
moderate,  almost  the  only  place  of  pain  is  anterior  and  about 
midway  between  the  knee  and  the  groin,  indicating,  we  suspect, 
some  obscare  affection  of  the  anterior  crural  nerve. 


CONCLUSIONS. 

The  history,  just  given,  indicates  the  progress  and  terminations 
of  these  irritable  diseases.  Locally,  a  sensitive  uterus  may  re- 
main unchanged,  even  for  years  at  a  time,  and  the  irritability 
may  eventually  disappear,  under  the  ever  varying  changes  in  the 


CONCLUSIONS.  223 

nervous  sensibility  of  the  patient  as  slie  gradually  becomes  less 
sensitive  to  local  irritations.  This  more  frequently  occurs  as  the 
patient  advances  in  years,  especially  when  the  menses  cease  to 
appear  and  the  phenomena  of  age  advance.  To  this  period  of  life 
many  unfortunates  anxiously  look  for  relief  to  their  sufl'erings, 
and  not  unfrequently  their  hopes  are  realized.  Yet,  in  many 
cases,  we  have  known  irritable  diseases  to  continue,  and  some- 
times actually  to  be  generated  after  this  "  change  of  life." 

In  mild  cases,  remedial  measures  may  greatly  assist  in  blunting 
the  morbid  sensibility,  so  that  the  patients  may  become  compara- 
tively comfortable  even  while  the  cause  remains  more  or  less 
operative.  The  idea  is  exemplified  by  the  fact,  often  mentioned, 
that  a  degree  of  local  irritation  is  often  easily  tolerated  by  the 
strong  and  robust,  which  would  torment  the  delicate  and  sen- 
sitive. 

In  more  severe  cases,  the  suffering  of  the  patient  may  continue 
for  many  years,  unless  the  cause  be  removed,  without  any  altera- 
tion of  tissue,  or  any  manifest  enlargement  or  swelling.  In  other 
cases  there  is  manifest  enlargement.  The  organ  is  developed, 
hj'-pertrophied ;  this  is  the  result  of  nervous  congestion  and 
increased  nutrition,  without  any  inflammation,  and  no  proper 
alteration  of  tissue.  Not  unfrequently  there  are  leucorrhoeal  and 
menorrhagic  discharges,  due  to  the  congestion.  There  seems  to 
be  no  evidence  that  alteration  of  structure  or  any  disorganization 
ever  results  from  mere  nervous  irritability  of  an  organ,  however 
long  it  may  exist.  It  may  be  complicated,  however,  with  inflam- 
mation, then  disorganization  may,  of  course,  ensue ;  but  this  is 
accidental  and  not  essential.  It  is  the  exception,  and  confirms, 
indeed,  the  general  principle,  that,  as  Dr.  Gooch  originally  de- 
clared, in  irritable  diseases  there  is  no  tendency  to  disorganiza- 
tion; "  Exceptio  probat  regulam."  The  natural  tendencies  of  the 
complaint  are,  eventually,  to  perfect  health.  When  the  cause 
has  been  removed,  recoveries  are  very  rapid;  so,  also,  as  the 
nervous  system  becomes  more  insensible  to  irritations,  any  local 
irritability  soon  disappears. 

The  same  is  true  of  the  spinal  and  cerebral  irritations  and  their 
reflex  influences.  They  disappear  rapidly,  the  local  disease  being 
cured ;  or,  they  may  be  diminished  or  destroyed  in  some  cases, 
after  the  lapse  of  years,  by  the  natural  changes  in  the  animal 
economy. 


224      PROGKESS    AND    RESULTS    OF    IRRITABLE    UTERUS. 

The  only  exceptions  to  these  remarks,  are  those  unfortunate 
individuals  who,  from  want  of  fresh  and  pure  air,  of  exercise, 
and  good  food,  or  from  improper  medical  treatment,  and  mental 
or  moral  causes  due  to  morbid  hereditary  predispositions  (such 
as  scrofula,  tuberculosis,  or  other  cachectic  diseases),  are  liable  to 
secondary  complaints,  which  may,  indeed,  prove  serious  and  de- 
structive :  and  also  those  who,  while  they  are  suftering  from 
irritable  affections,  have  inflammatory  or  febrile  diseases  super- 
added to  their  old  complaints.  These  complications  arising  from 
their  usual  causes,  are  each  prone  to  their  own  peculiar  termi- 
nations. 


CAUSES   AXD   PATHOLOaY  OF    IRRITABLE    DISEASES.      225 


CHAPTER    VIII. 

CAUSES    AND    PATHOLOGY    OF    IRRITABLE    DISEASES. 

The  causes  of  irritable  complaints  are  a  most  important  part 
of  their  history,  as  it  is  chiefly  by  investigating  them,  that  a  pro- 
per prognosis  and  an  efficient  treatment  can  be  established.  In 
the  phlegmasise  and  febrile  diseases,  the  causes  are  often  obscure, 
intangible,  and,  comparatively  seldom,  can  be  detected;  they  are 
generally  transient ;  as  soon  as  the  mischief  is  done,  the  cause  has 
often  vanished,  or  is  inoperative.  The  practitioner,  therefore,  has 
usually  to  contend  more  with  the  disease  than  its  cause ;  with 
the  consequences  of  a  poison  rather  than  with  the  poison  itself. 
This  is  a  general  truth,  but,  of  course,  there  are  many  excep- 
tions, especially  in  surgical  cases.  But,  in  all  the  varieties  of  spon- 
taneous inflammations,  in  the  head,  throat,  chest,  and  abdomen, 
as  well  as  in  the  extremities ;  in  all  those  from  internal  causes ; 
in  all  the  varieties  of  idiopathic  fevers ;  the  causes  are  usually 
unknown,  or  at  least  demand  no  modification  of  therapeutical 
remedies.  It  is  not  so,  however,  in  nervous  affections.  All 
remedies  avail  comparatively  little,  as  long  as  the  cause  continues 
operative.  They  are  palliative,  not  radical  in  their  character  and 
results.  The  only  sure  treatment,  permanent  as  well  as  efficient, 
is  the  removal  of  the  cause,  the  irritant  which,  acting  on  the  irri- 
tability of  the  tissues,  excites  "  nervous  irritation."  Too  much 
attention  cannot  be  paid,  therefore,  in  all  cases  to  the  investiga- 
tion of  the  sources  of  mischief  in  neurotic  affections. 

On  a  general  review  of  the  causes  of  irritable  diseases,  two 
grand  divisions  must  be  made :  the  one  respects  the  susceptibili- 
ties of  the  nervous  system,  whether  it  be  more  or  less  easily  dis- 
turbed; the  other  regards,  more  especially,  the  innumerable 
sources  of  irritation,  the  numerous  irritants  which  may  disturb 
the  nervous  sensitiveness.  The  former  may  be  classified  as  the 
'predisijosing^  the  latter  as  the  exciting  causes  of  nervous  diseases. 
The  predisposition  may,  however,  be  so  decided,  that  the  slightest 
15 


226      CAUSES   AND    PATHOLOGY    OF    lERITABLE    DISEASES. 

irritant  may  produce  severe  effects.  So,  also,  the  exciting  causes 
are  frequently  so  powerful,  that  no  peculiar  predisposition  is  re- 
quisite for  the  development  of  the  most  intense  examples  of 
nervous  irritation. 


PREDISPOSING  CAUSES.  ■ 

Neevous  Tempeeament. — The  most  frequent  predisposing 
cause,  in  all  probability,  is  ^^ natural  temperament^^''  the  '■^nervous 
temperament^''  as  it  is  usually  termed.  By  this  is  meant,  that  cer- 
tain individuals,  from  their  original  organization,  are  peculiarly 
impressible,  easily  disturbed,  easily  excited  or  depressed  in  every- 
thing that  regards  their  cerebro-spinal  nervous  system. 

It  may  be  said,  that  such  temperaments  are  often  hereditary; 
but  nevertheless,  they  are  frequently  observable,  even  early  in 
life,  when  no  decided  indications  of  such  susceptibility  could  be 
noticed  in  either  father  or  mother.  All  women  may  be  said  to 
be  nervous,  when  compared  with  men;  all  young  children,  when 
compared  with  adults;  young  girls  at  and  after  the  period  of  ado- 
lescence, when  compared  with  the  married  woman  in  the  matu- 
rity of  her  strength,  or  with  the  elderly  female  who  has  passed 
her  climacteric,  and  whose  sedateness  and  impassiveness  emulate 
that  of  the  stronger  sex.  When  girl  is  compared  with  girl,  the 
same  relative  differences  are  observed ;  some  are  apparently  un- 
excitable  in  their  physical,  intellectual,  or  moral  nature ;  while 
others  are  thrown  into  ecstasies  on  the  slightest  occasion,  and 
perhaps  are  depressed  with  the  same  facility;  in  other  words, 
they  are  nervous.  But,  as  has  already  been  mentioned,  this 
nervous  temperament,  although  not  unfrequently  found  in  the 
anasmic,  emaciated,  and  sesthenic  girl,  is  often  observed,  and, 
perhaps,  in  its  most  intense  manifestation,  in  girls  of  excellent 
organic  development  and  actions,  in  those  abounding  in  red 
blood,  with  active  circulation,  nutrition,  secretions,  and  excre- 
tions; in  those  of  a  full  habit,  and  who  are  active,  strong,  and 
capable  of  much  endurance.  Certainly,  every  one  must  have 
observed  great  nervousness  in  girls  whose  organic  life  was  per- 
fect. As  formerly  contended,  there  is  no  necessary  connection 
between  nervousness  and  anijemia.     There  is  often  great  anasmia, 


NEKVOUS    TEMPERAMENT.  227 

with  no  morbid  irritability,   and  the  reverse,   great  irritability 
with  no  anosmia. 

The  nervous  temperament  is  often,  however,  not  natural,  but 
acquired.  The  most  common  source  of  mischief  is  a  bad  physical 
education.  In  proportion  to  the  advancement  of  civilization ; 
the  multiplication  of  the  wants  and  duties  of  life ;  the  cultivation 
of  the  mind  and  the  sentiments  ;  the  influences  of  self-indulgence, 
of  confinement  in  ill-ventilated  rooms,  and  in  crowded  cities ;  the 
pleasures  of  the  table,  festive  assemblies,  and  all  the  appliances 
of  modern  luxury ;  the  mere  physical  system  degenerates,  and 
becomes  enervated,  sensitive,  and  irritable.  The  organic  actions 
are  feeble,  the  appetite  depraved,  the  digestion  imperfect,  and  of 
course  chylosis  and  hasmatosis  defective.  Aneemia,  deficient 
nutrition,  and  still  further,  exhaustion  and  nervousness  are  the 
common  and  unfortunate  results.  The  physical  being  is,  in  the 
present  state  of  society,  comparatively  neglected;  its  wants  are 
made  subservient  to  false  and  fatal  notions  of  mental  cultivation, 
or  forgotten  amid  the  fascinating  pleasures  of  sensual  existence. 
The  morbid  irritability,  thus  often  generated  in  early  life  by  a 
vicious  physical  education,  entails  years  of  mental,  moral,  and 
physical  suffering. 

Later  in  life,  the  same  nervous  sensitiveness  is  often  induced ; 
even  when,  originally,  the  health  and  strength  had  been  good, 
by  inordinate  mental  excitements,  or  luxurious  indulgences. 
Nervousness  is,  indeed,  the  almost  necessary  result  of  whatever 
debilitates.  It  is,  inversely,  as  the  strength  of  the  organic  or 
animal  system ;  all  the  direct  causes  of  exhaustion,  therefore,  in 
men  and  women,  render  them  more  sensitive,  more  irritable. 
The  loss  of  blood,  profuse  evacuations  from  the  stomach,  bowels, 
kidneys,  uterus,  mammee,  and  skin,  not  only  induce  anosmia  and 
exhaustion,  but  nervousness.  The  patient  becomes  more  excita- 
ble, as  she  becomes  weaker.  The  same  truth  appears  in  all  the 
indirect  causes  of  exhaustion,  from  previous  inflammatory  or 
febrile  complaints.  The  convalescent  is  proverbially  irritable, 
not  only  mentally  but  physically.  The  intemperate  becomes 
weakened  and  nervous  from  over-stimulation.  The  sensualist 
not  only  prostrates  the  powers  of  mind  and  body,  but  becomes 
the  victim  of  irritable  complaints.  In  this  view,  early  marriages 
predispose   to   nervous   aftections;    indeed,  marriage  not  unfre- 


228      CAUSES    AND    PATHOLOGY    OF    IRRITABLE    DISEASES. 

quently  is  the  cause  of  hysteria,  especially  in  erotic  habits,  and 
where  no  conception  ensues.  ' 

Eheumatism  and  Gout. — Intimately  connected  with  this  ex- 
citable state  of  the  system,  is  a  rheumatic  or  gouty  diathesis; 
which,  whether  in  its  active  or  passive  state,  predisposes  to  all 
the  variety  of  nervous  affections.  Often,  in  such  patients,  the  irri- 
tation is  fixed  upon  the  pelvic  viscera,  producing  all  the  symp- 
toms of  irritable  uterus  and  bladder.  Hence  we  frequently  hear 
of  rheumatism  and  gout  of  the  uterus. 

The  Parturient  State  predisposes  to  irritable  diseases  in 
various  ways.  As  soon  as  conception  occurs,  there  is,  as  every 
one  knows,  very  universally  an  exaltation  of  the  cerebro-spinal 
system.  This  exaltation  is  aggravated  by  innumerable  sources 
of  irritation  during  gestation,  not  forgetting  all  those  arising  from 
the  mental  and  moral  excitements  and  apprehensions  of  the  pa- 
tient. The  agonies  of  labor  leave  the  uterus  and  the  whole  or- 
ganism in  an  irritable  condition,  to  be  followed  frequently  by 
exhaustion  from  over-lactation,  the  loss  of  sleep,  the  anxieties  and 
other  causes  of  debility,  too  often  attendant  on  maternity,  espe- 
cially among  those  brought  up  in  luxury  and  refinement. 

Displacements  of  the  Uterus,  whether  in  the  single  or  the 
married  woman,  must  be  numbered  among  the  predisposing 
causes  of  irritable  affections,  as  will  hereafter  appear.  These  dis- 
placements constitute  the  chief  reason  why  females,  so  frequently, 
date  the  commencement  of  their  sufferings  from  one  of  their  con- 
finements, whether  premature  or  at  term. 

Climate. — The  exhausting  influences  of  a  warm  climate  on  the 
human  system  are  well  known  and  recognized.  The  inhabitants 
of  warm  countries  become  enervated  and  indolent.  Hence,  from' 
the  long  summers,  and  the  sedentary  habits  thereby  generated, 
nervous  affections  become  more  frequent.  Ladies  of  the  south 
suffer  comparatively  more  than  those  of  the  north,  not  because 
the  exciting  causes  are  more  numerous  or  ef&cieut ;  but  because 
the  nervous  system  is  more  excitable  from  the  influence  of  climate 
and  modes  of  living.  Slight  irritations  will  disturb  quickly  and 
sometimes  severely. 


GEXERAL    CONCLUSIONS.  229 

Case. — Among  many  cases  of  a  similar  character,  we  would  cite 
the  following :  A  very  interesting  young  married  lady  from  the 
south,  consulted  us  as  to  her  condition.  She  was  but  twenty-two 
years  of  age,  the  mother  of  two  children ;  she  had  a  healthy  ap- 
pearance, with  a  good  complexion,  and  was  free  from  all  organic 
irritations.  She  could  not  walk  about  without  uneasiness  or  ex- 
haustion, and  never  attempted  to  move  across  the  room  without 
an  "  abdominal  supporter,"  which  she  had  felt  forced  to  wear,  but 
with  great  inconvenience,  for  two  years.  Her  chief  complaint 
was  of  her  mind ;  she  was  troubled  by  peculiar  sensations  in  her 
head,  with  confusion  of  ideas.  "Doctor,"  she  said,  "I  have  been 
deranged  for  two  years,  and  am  not  much  better  at  present."  "We 
could  discover  no  other  source  of  irritation  about  her  system  than 
a  slight  prolapsus  uteri.  This  was  easily  relieved.  She  speedily 
felt  better  mentally  and  corporeally,  could  walk  without  band- 
ages with  ease  and  freedom,  and  once  more  enjoyed  the  pleasures, 
of  life.  In  a  letter  written  soon  after  her  return  home,  she  said  : 
"This  beautiful  world,  which  I  could  not  look  upon  without  hor- 
ror and  disgust,  has  become  again  a  source  of  delight;"  "I  could 
not  wish  my  worst  enemy  to  suffer  as  I  have  done,  even  for  the 
pleasures  I  now  enjoy."  Years  have  elapsed,  during  which  she 
has  given  birth  to  several  children,  and  has  had  no  return  of  her 
nervous  distress. 

General  Conclusions. — This  and  analogous  cases  demon- 
strate, that  severe  and  urgent  symptoms  may  arise  from  trifling 
causes,  in  persons  whose  natural  or  acquired  temperament  is  irrita- 
ble. Another  inference,  also,  is  perfectly  legitimate,  that  in  many 
cases,  no  decided  suffering  will  arise,  even  from  well-marked  local 
irritation,  when  there  is  no  predisposition.  Hence,  for  example, 
displacements  of  the  uterus  in  the  vigorous,  insusceptible  women, 
will  often  exist  even  for  a  long  time  with  apparent  impunity. 
Another  fair  inference  of  a  similar  character  should  be  stated ; 
that  females  may  often  recover,  partially  or  completely,  by  de- 
stroying the  predisposition,  the  morbid  irritability,  even  when  a 
local  irritation  of  moderate  character  continues.  As  they  gain 
strength,  for  example,  they  become  less  sensitive,  and,  of  course, 
are  less  disturbed  by  any  local  trouble.  They  become  stronger 
and  able  to  bear  it. 


230      CAUSES   AND   PATHOLOGY   OF   IRKITABLE    DISEASES. 

EXCITING  CAUSES. 

The  predisposing  causes  here,  as  in  other  diseases,  may  often 
become  also  the  real  exciting  causes  of  nervous  affections ;  but 
usually  there  is  some  other  irritant,  of  greater  or  less  power, 
operative.  A  slight  irritation  will  produce  severe  symptoms 
when  the  predisposition  is  strong;  and,  on  the  contrary,  even 
when  no  predisposition  whatever  exists,  a  more  decided  local 
irritation  will  be  also  followed  by  severe  symptoms. 

Inflammatory  Congestion. — Congestion  has  been,  very  gene- 
rally, regarded  as  the  usual  cause  of  all  the  suffering  arising  from 
irritable  uterus.  As  formerly  intimated,  no  very  precise  notion 
has  been  connected  with  this  word  and  its  French  synonym, 
^  engorgement ;  and  no  particular  attention  has  been  paid  to  the 
different  circumstances  under  which  vascular  turgescence  occurs 
in  the  animal  economy.^  The  two  varieties  of  active  congestion 
already  insisted  on,  the  one  depending  on  nervous  irritation  and 
the  other  on  organic  irritation,  must  always  be  borne  in  mind, 
differing,  as  they  do,  so  much  in  their  immediate  and  remote 
consequences.  The  one  is  properly  simple  congestion  or  engorge- 
ment, the  other  is  inflammation.  Both  have  been  regarded  as  the 
cause  of  an  irritable  condition  of  an  organ. 

As  respects  simple  congestion,  this  has  been  and  still  is  a 
great  error,  theoretically  and  practically.  Congestion  is  not  the 
cause,  but  the  sequence  of  nervous  irritation.  It  is  impossible  to 
conceive  of  blood  rushing  to  any  spot,  tissue,  or  organ,  under 
the  equable  action  of  the  heart  and  large  arteries,  unless  some 
previous  change  has  occurred  in  such  tissue.  An  apoplexy  or 
determination  of  blood  to  the  brain  presupposes  a  determining 
cause,  an  irritant  producing  an  irritation — "  Ubi  irritatio,  ibi 
affluxus."  Another  reason  for  entirely  disregarding  this  kind  of- 
congestion  as  a  cause,  is,  its  evanescent  character.  In  blushing,  in 
lachrymation,  and  in  the  erections,  as  soon  as  the  nervous  excite- 
ment ceases,  the  turgescence  disappears  with  wonderful  rapidity, 
leaving  no  vestige  of  its  visitation.  In  morbid  congestions,  also, 
with  certain  limitations,  the  same  remark  is  true.     Active  con- 

'   Vide  Introduction. 


INFLAMMATORY    COXGESTIOX,  231 

gestion  of  tlie  brain,  heart,  lungs,  liver,  and  uterus  (as  in  severe 
cases  of  dysmenorrhoea),  generally  vanishes  with  great  rapidity 
and  completeness  if  the  cause  subsides. — "Causa  sublata,  effect  us 
tollitur." 

The  same  observations  are,  in  some  respects,  true  as  regards 
inflammatory  congestion.  Here,  also,  the  turgescence  presupposes  a 
cause,  an  irritant  acting  on  the  irritability  of  the  tissues  of  organic 
life;  hence  organic  irritation,  then  inflammation.  The  surgeon  well 
knows  how  soon  inflammation  is  resolved  if  the  mote  be  taken 
from  the  eye  or  the  thorn  from  the  flesh.  But,  unfortunately, 
many  inflammations  are  kept  up  by  irritants  which  cannot  be 
removed,  or  depend  on  spontaneous  causes,  such  as  peculiar  states 
of  the  patient's  general  system  or  of  his  fluids ;  and  hence,  they 
are  persistent.  Moreover,  the  nature  or  character  of  organic  or 
inflammatory  irritation  is  peculiar;  it  not  only  involves  the  sensi- 
bilities of  the  tissues,  but  has  a  tendency  to  produce  alteration  or 
actual  disorganization.  On  these  accounts,  inflammation  is  often 
the  cause  of  an  irritable  state  of  a  tissue.  In  acute  cases  of  in- 
flammation, pain,  and  not  unfrequently  spasms  (symptoms  of 
nervous  irritation),  are  often  present,  even  in  the  earliest  stage, 
and  become  more  or  less  intense  in  its  progress.  Occasionally, 
also,  the  nervous  irritation,  especially  when  a  strong  predisposi- 
tion exists,  is  inordinate  compared  with  the  degree  of  inflamma- 
tory irritation  present.  This  is  observed  in  some  of  the  varieties 
of  rheumatism  and  gout,  of  gastro-intestinal  and  uterine  inflam- 
mations of  even  a  very  moderate  character.  Often,  indeed,  the 
symptoms  of  nervous  irritation  are  so  urgent  as  to  demand  almost 
the  sole  attention  of  the  practitioner,  those  of  inflammation  being 
put  in  abeyance  for  the  time  being. 

Frequently,  however,  even  in  such  cases,  the  inflammation  be- 
ing removed,  the  pain  and  spasms  disappear.  Nevertheless  it  is 
a  truth,  which  the  profession  has  been  slow  to  learn,  that  in  many 
cases  after  inflammation  has  been  dissipated,  the  part  affected  re- 
mains tender,  sensitive,  and  irritable,  not  only  for  days,  but  some- 
times for  months  and  years.  This  fact  is  recognized  by  the  popu- 
lar word  "  weakness."  An  organ  once  diseased  is  regarded  as 
"  weak ;"  that  is,  easily  disturbed,  or  predisposed  to  be  diseased 
again.  Brodie  fixed  the  attention  of  surgeons  on  this  idea  when 
he  spoke  of  "the  hysteric  condition"  of  the  mammge,  of  the  joints, 
etc. ;  and  Gooch,  more  clearlj^  than  any  one  else,  developed  the 


232      CAUSES    AN'D    PATHOLOGY   OF    IRRITABLE    DISEASES. 

distinct  idea  of  a  morbidly  sensitive  organ  without  any  inflam- 
mation, when  he  described  so  graphically  an  "  irritable  uterus," 
and  traced  the  history  of  its  phenomena. 

Inflammation,  therefore,  is  sometimes  the  cause,  immediate  or 
remote,  of  an  irritable  uterus.  This  is  not  only  true  of  the  com- 
mon forms  of  metritis,  but  of  those  peculiar  varieties  connected 
Avith  rheumatic,  gouty,  cutaneous,  and  other  metastatic  forms  of 
disease.  In  all  of  these  latter  there  may  be  rapid  translations  to 
and  from  the  uterus,  with  some  suffering  at  the  time,  but  leaving 
the  organ  exceedingly  sensitive  or  in  a  state  of  actual  irritation. 
Too  much  has,  however,  been  lately  said  of  rheumatism  and 
gout  of  the  uterus  to  the  exclusion  of  other  causes  far  more 
common. 

Parturition. — The  sensitive  state  of  the  uterus  during  preg- 
nancy is  aggravated  and  sometimes  confirmed  by  the  sufi'erings 
of  labor,  and  occasionally  hy  the  inflammatory  consequences  of  a 
tedious  and  painful  delivery.  For  weeks  and  months,  the  uterus 
may  remain  so  irritable  as  to  become  the  centre  of  irritation  to 
other  tissues  and  organs.  Owing  to  the  enlargement  of  the  uterus 
continuing  after  delivery,  and  especially  to  the  elongated  and 
consequent  inefficiency  of  its  ligaments,  as  will  be  explained 
more  fully  hereafter,  displacements  of  the  organ  ensue,  perhaps, 
more  frequently  than  under  other  circumstances,  and  thus  lay 
the  foundation  of  great  and  prolonged  suffering.  Often,  therefore, 
do  females  date  the  origin  of  their  sufferings  from  a  particular 
"  confinement." 

Over-Lactation. — The  continual  irritation  of  the  mamm£e, 
produced  by  over-lactation,  acts  not  only  as  a  predisposing  cause, 
by  exhausting  the  patient's  strength,  and  thus  rendering  the 
nervous  system  more  sensitive,  but  often  has  a  direct  influence  on 
the  uterus,  increasing  its  sensitiveness  and  rendering  it  morbidly 
irritable. 

It  is  well  known,  that  putting  the  child  to  the  breast  soon  after 
delivery  is  an  exciting  cause  of  after-pains.  In  protracted  cases 
of  nursing,  especially  when  the  milk  is  deficient,  the  act  of  suck- 
ling is  often  followed  by  pain  in  the  back  and  other  evidences  of 
uterine  irritation ;  and,  if  persisted  in,  may  be  productive  of  bad 
consequences. 


MENTAL    EXCITEMENTS.  233 

"  NiMiA  Yenus,"  excessive  coitus,  and  all  unnatural  excitations, 
are  frequently  direct  causes  of  an  irritable  uterus.  It  is  often 
observed,  therefore,  some  time  after  marriage,  particularly  in 
cases  where  no  conception  has  taken  place. 

Mental  and  Moeal  Excitements. — In  close  connection  with 
the  last  mentioned  cause  are  all  those  innumerable,  indirect  but 
positive  excitements  of  the  uterine  system,  which  act  through  the 
medium  of  the  imagination  and  passions — through  the  brain — 
on  the  ovaries  and  uterus. 

Hence  not  only  is  a  predisposition  established,  but  positive 
morbid  irritation  induced,  by  the  indulgence  of  voluptuous  imagin- 
ings, whether  arising  spontaneously,  or  generated  by  improper 
and  loose  conversation,  by  the  reading  of  romances,  novels,  plays, 
or  books  still  more  impure,  and  by  attendance  at  the  ball-room 
and  the  theatre.  Everything  of  the  kind  has  a  terrible  influence, 
especially  on  young  girls  of  a  warm,  excitable  temperament. 
These  causes,  combined  with  a  bad  physical  education,  luxurious 
indulgences,  sedentary  habits,  and  other  violations  of  the  rules  of 
hygiene,  constitute  a  prolific  cause  of  irritable  and  nervous 
diseases. 

Moreover,  much  mischief  is  the  result  of  undue  mental  excite- 
ment in  young  persons,  even  if  the  morale  be  properly  cultivated. 
The  prolonged  exercise  of  the  mental  powers  produces  corporeal 
weakness.  It  positively  exhausts,  and  thus  renders  the  brain  and 
its  dependencies,  sensitive,  and  irritable ;  so  that  everj^  organ,  the 
uterus  especially,  becomes  morbidly  excitable.  The  brain  itself 
yields,  and  even  mental  exhaustion,  as  well  as  physical,  too  often 
results  from  the  inordinate  and  injudicious  effort  to  cultivate  the 
intellectual,  at  the  expense  of  the  physical  being.  This  is,  no 
doubt,  the  reason  of  the  frequent  failure  of  the  prevalent  system 
of  education.  All  the  branches  of  human  learning,  considered 
as  requisite  for  a  lady,  and  all  the  "  accomplishments,"  are  to  be 
gained  in  some  five  or  six  years,  with  an  almost  total  disregard 
of  the  organic  and  animal  functions.  No  wonder,  then,  that  girls, 
on  leaving  school,  become  so  soon  the  "  living  martyrs"  of  nerv- 
ous, irritable  diseases. 

Cold. — The  symptoms  of  irritable  uterus  are  very  frequently 
referred  by  patients  to  "  cold^''''  that  is,  to  some  unusual  exposure 


234:      CAUSES  AND    PATHOLOGY   OF    IRRITABLE    DISEASES. 

to  a  cold  atmospliere,  or  to  some  sudden  transition  of  temperature. 
Strictly,  this  is  never  quite  correct,  as  tlie  direct  influence  of  cold 
probably  never  excites  either  organic  or  animal  irritation.  Still, 
however,  as  cold  is  a  cause  of  various  functional  disturbances  of 
the  uterus,  such  as  amenorrhosa,  dysmenorrhoea,  etc.,  and  also  of 
various  kinds  and  degrees  of  inflammatory  action,  it  becomes  in- 
directly the  cause  of  irritable  uterus. 

Great  Muscular  Effort,  especially  when  suddenly  made, 
excites  the  uterine  sensibilities,  and,  directly  or  indirectly,  is  a 
most  frequent  cause  of  morbid  irritability  of  the  uterus.  Hence, 
patients  very  frequently  date  the  commencement  of  their  troubles 
to  a  long  fatiguing  walk ;  to  climbing  some  high  hill,  mountain, 
or  tower ;  to  ascending  and  descending  liigh  staircases ;  to  severe 
jolting  on  horseback,  or  in  coaches ;  to  dancing,  running,  jump- 
ing;  to  falls;  to  sneezing,  coughing,  vomiting,  straining  at  stool; 
to  lifting  or  carrying  weights;  to  dandling  children  in  the 
arras,  etc. 

If  the  exertion  be  suddenly  made,  it  is  much  more  injurious; 
and,  of  course,  the  bad  effects  are  decidedly  more  readily  mani- 
fested when  any  predisposition  exists.  Thus,  after  parturition, 
when  all  the  excitements  of  gestation  and  labor  have  left  the 
pelvic  organs  unusually  sensitive,  a  slight  muscular  effort,  as  in 
walking,  standing,  or  defecation,  will  often  prove  permanently 
injurious. 

The  uterus  in  all  cases  of  violent  or  prolonged  muscular  effort 
is  impelled  more  or  less  forcibly  against  the  floor  of  the  pelvis, 
by  the  Aveight  of  the  superincumbent  viscera,  and  by  the  action 
of  the  abdominal  muscles  and  diaphragm.  Under  the  continual 
repetition  of  such  pressure  from  above,  resisted  by  the  sacrum, 
the  coccyx,  and  the  rectum,  often  filled  with  indurated  fasces,  the 
uterus  gradually  becomes  more  and  more  sensitive,  and  thence 
arises  more  or  less  sympathetic  distress. 

Nevertheless,  it  is  indirectly  that  these  physical  efforts  are 
chiefly  deleterious.  They  all  have  a  direct  agency  in  causing  a 
permanent  disjolacement  of  the  uterus,  by  stretching  its  ligaments, 
so  as,  sooner  or  later,  to  render  them  incapable  of  sustaining  this 
viscus  in  its  natural  location.  The  causes  and  the  effects  of  sucli 
displacements  will  hereafter  form  the  subject  of  special  investi- 
gation.    It  will  be  sufficient  now  to  state,  that  under  these  cir- 


DISEASES    OF    THE    UTERUS.  235 

CLimstances  of  displacement,  the  uterus  is  subjected  constantly  to 
irritation  on  every  movement  of  the  patient,  and  may  thus  be 
rendered  so  irritable,  that  the  most  terrible  consequences  will 
result.  Displacements  of  the  uterus,  however  induced,  and 
whether  with  or  without  a  predisposition  to  nervous  irritation, 
become,  as  will  hereafter  be  shown,  the  most  pi'olific  cause  of  an 
irritable  state  of  this  organ.  Even  when  other  causes  are  opera- 
tive, the  symptoms  are  often  enhanced  and  kept  up  by  this  unfor- 
tunate accident;  indeed,  not  unfrequently,  they  will  often  dis- 
appear, when  other  supposed  mal-influences  exist,  if  the  dis- 
placement be  relieved. 

Pressure  made  on  the  uterus  from  other  sources  than  mus- 
cular action,  is  often  equally  injurious,  especially  as  all  such 
extraneous  force  receives  an  additional  impetus  from  every  mo- 
tion of  the  patient.  The  tight  dresses,  the  corsets,  the  various 
bands  and  strings  around  the  waist,  the  weight  of  the  lower  gar- 
ments, the  use  of  binders,  of  abdominal  supporters,  and  all  the 
variety  of  braces,  too  often  employed  merely  to  hide  trifling 
deformities;  all  operate,  directly  by  the  unnatural  pressure  made 
on  the  uterus,  or  still  more  powerfully,  indirectly,  by  forcing  this 
organ  into  various  mal-positious,  which  are  a  constant  source  of 
irritation. 

Similar  results  may  be  met  with,  from  internal  pressure,  from 
tympanites  or  ascites,  from  enlarged  liver,  spleen,  or  mesenteric 
glands,  from  feculent  accumulations  in  the  bowels,  from  enlarged 
ovaries,  with  or  without  dropsical  collections;  all  of  which  may 
directly  irritate  the  pelvic  viscera,  or  may  cause  displacements 
of  the  uterus. 

Diseases  of  the  Uterus. — In  affections  of  the  uterus  itself,  the 
same  remark  is  still  more  frequently  substantiated.  Hence,  hyper- 
trophy and  indurated  states  of  the  womb,  tumors  within  or  on  the 
exterior  of  the  uterus,  or  in  its  substance  (intra-mural),  physo- 
metra,  hydrometra,  and  abscesses  of  the  organ,  not  merely  excite 
the  organic  and  animal  actions  of  this  viscus;  but  by  increasing 
its  weight,  and  by  affording  a  broader  surface  to  pressure  from 
the  intestines,  etc.,  they,  almost  necessarily,  cause  displacements, 
which    are   followed    by   irritation   or   congestion,    leucorrhoea, 


236      CAUSES   AND    PATHOLOGY    OF    IRRITABLE    DISEASES. 

menorrhagia,   hemorrhage,   etc.     Proofs    of  this   important   fact 
will  hereafter  be  adduced,  when  the  treatment  is  considered. 

Obstructions,  partial  or  complete,  of  the  cervix  uteri, 
particularly  during  the  menstrual  life,  often  become  the  source 
of  great  irritation.  The  uterus  is  very  intolerant  of  any  fluid,, 
retained  within  its  cavity.  If  the  mucoid  or  menstrual  secretions 
have  not  a  ready  outlet,  irritation  and  painful  contractions  ensue, 
constituting  mechanical  dysmenorrhoea.  The  constant  periodical 
recurrence  of  which  will  render  the  tissues  of  this  organ  preter- 
naturally  sensitive. 

Irritations  of  other  Organs. — Finally,  the  uterus  is  dis- 
turbed by  its  sympathetic  connections,  in  cases  of  irritation  or  dis- 
ease of  other  organs^  as  the  ovaries,  the  bladder,  the  clitoris,  the 
vulva,  and  the  rectum,  especially  its  extremity,  so  often  the  sub- 
ject of  painful  diseases,  also  from  the  more  distant  organs,  as 
intestines,  stomach,  mammae,  brain,  etc.,  to  which  allusions  have 
already  been  made.  These  reflex  influences  on  the  uterus  are 
often  very  ef&cient  in  producing  mischief. 

General  Conclusions. — A  review  of  these  causes  of  irritable 
uterus  will,  to  a  great  extent,  enable  us  to  answer  the  repeated 
inquiry,  why  nervous  affections  of  the  uterus  are  so  much  more 
prevalent  and  distressing  during  the  present  than  the  past  gene- 
ration. The  answer  is  twofold,  or,  perhaps,  threefold.  The  first 
relates  to  the  predisposing  states  of  the  patient's  system.  The 
nervous  temperament  of  women  of  the  present  age  has  been 
greatly  developed  by  the  wonderful  increase  of  the  indulgences 
and  luxuries  of  modern  life.  The  physical  education  of  the  girl 
has  been  most  carelessly  and  thoughtlessly  disregarded ;  while 
every  stimulus  has  been  applied  to  procure  a  precocious  develop- 
ment of  the  mind,  the  heart,  and  the  passions.  The  organic  life 
has  been  neglected,  while  the  animal  has  been  unduly  and  too 
rapidly  excited.  Another  answer  to  the  query  is,  that  the  tight 
dresses,  the  weight  of  garments,  the  braces,  etc,  to  which  girls 
are  subjected,  are  more  constantly  resorted  to,  and  are  of  a  more 
decided  character  than  those  employed  by  their  ancestors. 

Perhaps  it  should  be  added,  that  the  greater  frequency  of  ute- 
rine diseases  is  more  apparent  than  real.     Formerly  these  com- 


GENERAL    CONCLUSIONS.  237 

plaints  passed  under  other  names,  as  weakness  of  the  general 
system,  nervousness,  rheumatism,  gout,  affections  of  the  head, 
heart,  lungs,  stomach,  liver,  or  even  of  the  bowels.  Patients 
were  regarded  as  complaining,  as  addicted  to  secret  vices,  to  in- 
temperance in  alcohol  or  opium.  Even  of  late  years,  neuralgia, 
spasms,  and  especially  that  most  convenient  word,  "spinal  irrita- 
tion," have  received  the  credit  of  all  the  varieties  of  uterine  affec- 
tion. The  uterus,  as  a  source  of  spinal  and  cerebral  irritation,  of 
neuralgia,  spasms,  and  convulsions,  has  been,  and,  perhaps,  still  is 
too  often  ignored.  Even  women  themselves,  as  well  as  their  medi- 
cal attendants,  have,  often,  not  surmised  the  source  of  irritation. 

Case. — We  have  just  taken  charge  of  a  patient,  with  hysteric 
faintings,  spasms,  and  convulsions,  who  for  some  months  had  been 
treated  for  inflammations  of  the  brain  and  the  spinal  marrow,  by 
profuse  bleedings,  cupping,  leeching,  mercurials,  and  evacuants, 
and  all  the  variety  of  counter-irritants,  to  the  scalp,  spine,  etc. 
During  the  employment  of  these  so-called  remedies,  the  symp- 
toms constantly  increased  in  violence.  For  the  last  three  months, 
medical  treatment  has  been  abandoned,  and  she  has  improved. 
Many  of  her  nervous  affections,  however,  continue.  She  had  a 
retro  verted  uterus  with  hypertrophy ;  we  could  detect  no  other 
disease  in  any  organ  of  her  system. 

All  ages  are  liable  to  irritable  diseases ;  but  the  uterus  is  very 
seldom  involved  until  the  occurrence  of  puberty.  We  have  had 
patients,  who  traced  the  symptoms  of  uterine  irritation  to  one  or 
even  two  years  before  the  appearance  of  their  catamenia,  which 
were,  however,  behind  the  usual  time.  It  is  during  the  menstrual 
life  of  woman  that  such  complaints  most  generally  occur.  A 
strong  predisposition  is  seen,  as  soon  as  this  most  wonderful 
change  begins  in  the  ecoi^omy:  for,  then  not  only  the  ovaries  and 
the  uterus  are  most  rapidly  developed  to  their  perfect  organiza- 
tion ;  but  analogous  changes  occur  in  all  the  tissues  and  organs 
of  the  body.  It  is  when  the  brain,  as  the  organ  of  the  mental 
and  moral  being,  as  well  as  the  source  and  centre  of  all  nervous 
influences,  attains  the  full  development  of  its  structure  and  its 
functions,  that  the  peculiar  irritability  and  sensibility  of  the  woman 
are  fully  developed,  and  the  predisposition  for  neurotic  complaints 
becomes  most  marked.  The  history  of  the  symptoms,  already 
given,  illustrates  these  facts.  When  the  menstrual  life  termi- 
nates, the  ovaries  and  the  uterus  rapidly  lose  their  influence ;  the 


238      CAUSES   AND    PATHOLOGY    OF    IRRITABLE     DISEASES. 

organic  actions  often  become  more  active,  and  tlie  cerebro-spinal 
system  loses  its  sensibility  to  a  greater  or  less  degree,  so  that  the 
hysterical  forms  of  complaint  are  far  less  frequent.  Neverthe- 
less, irritable  diseases  sometimes  originate  after  the  disappearance 
of  the  menses,  and  when  they  existed  previously,  are  often  con- 
tinued, even  severely,  for  years;  still,  it  is  a  general  truth,  that- 
neurotic  diseases  disappear  at  fifty  years  of  age.  The  married 
woman  looks  forward  with  pleasure  to  this  golden  period  of  her 
existence,  when  the  sufferings  of  maternity  shall  cease.  The 
martyrs  of  neuralgic  complaints  (always  dying  but  still  sur- 
viving), whether  single  or  married,  whether  blessed  with  children 
or  denied  this  great  privilege  of  women,  bend  their  thoughts  and 
wishes  to  the  same  important  epoch.  Far  off  it  may  be,  years 
may  still  have  to  elapse,  years  of  wretchedness  and  suffering, 
mental,  moral,  and  physical,  during  which  the  prayer  for  death 
will  often  be  breathed;  still  the  hope  arises,  and  should  be  en- 
couraged, that  amid  the  revolutions  of  the  animal  functions,  pain 
and  distress  will  cease,  the  blessing  of  health  will  be  again 
granted,  life  will  present  new  and  unAvonted  charms,  and  the 
mind  and  spirit  rejoice  under  the  soothing  influence  of  natural 
sensations  and  normal  stimuli.  If  no  organic  disease  has  been 
superadded,  the  recovery  may  be  complete. 

Happily,  however,  by  attention  and  appropriate  treatment, 
irritable  diseases  can  often  be  arrested,  and  health  and  happiness 
restored  long  before  the  period  of  the  cessation  of  the  menses. 


PATHOLOGY. 

The  nature  of  this  form  of  morbid  |xcitement,  as  here  advo- 
cated, has  already  been  developed. 

An  irritable  uterus  is  that  state  of  the  nerves  of  the  organ,  in 
which  they  are  preternaturally  susceptible  to  impressions.  This 
is  all.  There  may  be,  and  often  is,  no  perceptible  disturbance  of 
the  organic  life.  It  is  merely  a  disease  of  the  animal  life.  If, 
however,  a  severe  or  continued  irritant  disturbs  this  irritability, 
the  irritation  may  be  followed  by  pain,  spasm,  or  by  various  dis- 
tressing nervous  sensations,  which  may  radiate  to  distant  parts. 
In  other  cases  it  is  succeeded  by  congestion  or  engorgement. 
This  is  not  inflammatory  congestion,  but  that   modification  of 


PATHOLOGY.  239 

congestion  resulting  from  nervous  excitements,  as  in  menstrua- 
tion, erections,  etc.  This  congestion  may  be  the  cause  of  leucor- 
rhoea,  menorrhagia,  and  haemorrhagia.  Sometimes,  when  long 
persistent,  and  especially  when  no  secretions  or  effusions  ensue 
for  its  relief,  congestion  is  followed  by  increased  growth  or 
development  of  the  organ,  that  is,  by  hypertrophy,  but  never  by 
inflammation,  by  induration,  ulceration,  or  other  results  of  in- 
flammatory action.  Hence,  there  is  no  permanent  alteration  of 
structure;  even  after  the  lapse  of  many  years,  the  recovery  is 
perfect,  and  often  sudden.  Of  course  inflammation  is  often  co- 
existent with  an  irritable  uterus ;  but  it  arises  from  other  and 
extraneous  sources.  On  the  other  hand,  an  irritable  tissue  often 
ensues  from  inflammation,  which  irritability  is  thus  sometimes  the 
effect,  but  never  the  cause. 

This  simple  distinct  view  of  an  irritable  organ  does  not  seem 
to  have  been  received  by  the  profession ;  even  Gooch,  notwith- 
standing his  admirable  description  of  the  disease,  treated  it  as  an 
inflammatory  complaint.  His  successors  have  followed  him  in 
practice,  and  have  expressed  their  theoretical  views  by  numerous 
modified  terms.  Thus  we  read  of  a  moderate  degree  of  inflam- 
mation; of  a  passive  or  sub-inflammation;  of  a  continued  dj-s- 
menorrhoea;  of  rheumatism  or  gout  of  the  uterus;  of  inflammation 
slowly,  after  the  lapse  of  years,  tending  to  disorganization;  of  a 
peculiar  irritation,  not  tending  to  recovery;  of  congestion  of  the 
uterus ;  of  engorgement ;  and  lately  we  hear  constantly  the  posi- 
tive, unmodified  declaration,  that  it  is  nothing  more  than  inflam- 
mation of  the  mucous  membrane  of  the  os,  cervix,  and  sometimes 
of  the  body  of  the  uterus,  followed  by  its  usual  consequences. 
The  practice,  most  unfortunately,  of  authors  and  theorists  is 
founded  on  these  different  pathological  views. 

The  numerous  and  varied  opinions  of  pathologists  on  this  sub- 
ject, in  Europe  and  America,  as  evinced  by  books,  and  by  the 
excited  debates  in  medical  societies,  cis-  and  trans-atlantic,  are 
anj^thing  but  creditable  to  medical  science.  All  must  mourn 
over  a  discrepancy  of  opinion,  which  bears  so  directly  on  the 
treatment  of  such  painful  and  distressing  maladies. 


2-iO      CAUSES   AND    PATHOLOGY    OF    IRRITABLE    DISEASES. 

DIAGNOSIS. 

The  diagnosis,  in  one  point  of  view,  is  exceedingly  easy.  We 
must  simply  ascertain,  in  order  to  pronounce  it  irritable,  whether 
a  part  be  morbidly  sensitive ;  whether  its  sensations  be  more 
readily  disturbed  than  natural.  But,  the  practical  difficulty  is  to 
determine  whether  this  excitable  state  is  merely  the  result  of 
inflammation,  or  whether  it  arises  from  some  other  irritant.  In 
other  words,  to  distinguish  between  a  state  of  nervous  and  of 
organic  irritation ;  between  an  irritable  and  an  inflamed  organ. 

In  pure  uncomplicated  cases  of  irritable  uterus,  the  absence  of 
all  the  symptoms  and  the  consequences  of  inflammation,  would 
seem  to  be  sufficient.  But,  it  has  been  objected,  that  all  the  symp- 
toms of  inflammation  are  not  absent ;  that  the  pain,  the  soreness, 
the  burning,  the  disturbance  of  function,  which  are  present,  are 
all  evidences  of  phlogosis.  This  difficulty  has  already  been  met, 
when  the  great  pathological  fact  was  presented,  that  pain  has  no 
necessary  connection  with  inflammation,  that  it  is  an  accident  or 
an  accessory  to  this  state  of  morbid  excitement.  We  know  that 
some  of  the  most  destructive  inflammations  exist  without  pain ; 
and  also  that  the  most  intense  agony  which  animal  nature  can 
endure,  is  often  experienced  without  inflammation.  If,  therefore, 
the  case  be  a  doubtful  one,  yet,  after  the  lapse  of  weeks,  or  months, 
or  years,  none  of  the  usual  consequences  of  inflammation  be  ob- 
servable, the  organ  may  safely  be  regarded  as  irritable.  This 
diagnosis  will  be  confirmed,  if  the  general  health  of  the  patient 
remains  good,  with  no  decided  or  continued  emaciation,  and  no 
fever,  etc. 

The  difficulty  is  greater  when  local  inflammation  exists  with 
an  irritable  uterus.  This  point  has  also  been  noticed.  If  the 
symptoms  of  nervous  irritation  be  decidedly  predominant,  Ave 
may  regard  it  as  a  case  of  irritable  uterus,  complicated  with  in- 
flammation, and  demanding  not  only  treatment  for  the  inflamma- 
tion,  but  afterwards  a  subsequent  and  diverse  treatment,  for 
nervous  irritation.  Even  in  bad  cases  of  inflammation,  when  en- 
largement and  induration  of  the  cervix,  a  red,  tumid,  and  granu- 
lar condition  of  its  mucous  membrane  and  purulent  discharges 
are  present ;  even  in  such  cases,  the  neuralgic  pains  will  very  fre- 
quently be  found  dependent,  mainly  on  pressure  and  other  causes, 


PROGNOSIS.  241 

rather  than  on  the  iDflammatory  process.  It  is  inflammation  com- 
plicated with  an  irritable  nterus.  This  distinction  will  be  found 
of  great  practical  importance. 

Again,  care  must  be  taken  not  to  suppose  an  organ  to  be  in- 
flamed, simply  because  it  is  painful,  and  at  the  same  time  enlarged 
and  indurated.  Often,  in  such  cases,  there  is  no  inflammation 
present ;  the  induration  is  the  result  of  a  bygone  inflammation ; 
it  is  a  sequence,  not  a  symptom.  The  pain  and  spinal  irritation 
still  remaining,  are  evidences  of  an  irritable  organ. 

The  same  remark  and  mode  of  reasoning  are  applicable  to  all 
those  cases  of  irritable  uterus,  conjoined  with  simple  hypertrophy, 
with  a  hypertrophic  enlargement  depending  on  pregnancy,  poly- 
pous tumors,  or  heterologue  developments  in  the  substance,  or 
on  the  surface  of  the  uterus.  Too  often  have  all  such  cases  been 
confounded  with,  and  treated  as,  inflammation. 

Of  course,  also,  care  should  be  taken,  that  when  symptoms  of 
pelvic  irritation  be  present,  its  true  locality  be  ascertained  as 
far  as  practicable.  Frequently,  on  account  of  the  predominance 
of  the  rectal  irritation,  have  all  the  symptoms  of  irritable  uterus 
been  referred  to  rectitis,  to  strictures,  or  to  hsemorrhoidal  tumors ; 
to  fissure  of  the  anus,  or  to  fistula  in  ano.  So  also  the  cystic 
irritation,  so  common,  has  often  been  regarded  as  a  disease  of 
the  blood,  kidneys,  or  urinary  passages ;  yet  the  original  com- 
plaint was,  and  continued  to  remain  in  the  uterus. 

Perhaps,  under  this  head  of  diagnosis,  the  caution  should  be 
reiterated,  not  to  consider  any  of  the  secondary  or  sympathetic 
symptoms  of  irritable  uterus  as  primary  or  original,  and,  espe- 
cially, not  to  confound  nervous  irritation  of  the  brain,  lungs,  liver, 
etc.,  with  inflammatory  or  organic  diseases  of  these  organs. 


PROGNOSIS. 

The  prognosis,  of  course,  in  all  nervous  affections,  must  be 
doubtful ;  nevertheless,  in  pure  uncomplicated  cases  it  may  be 
regarded  as  quite  favorable.  In  such  cases,  however  severe  and 
prolonged  the  suffering,  death  very  rarely  results.  On  the  con- 
trary, a  perfect  recovery  may  be  very  confidently  anticipated  in 
most  of  the  cases,  and  occasionally  the  restoration  to  health  is 
very  rapid.  Where  complications  exist,  the  prognosis  depends 
16 


242      CAUSES   AXD   PATHOLOGY   OF   IRRITABLE    DISEASES. 

on  the  character  and  degree  of  the  complication,  whether  curable 
or  incurable,  whether  mild  or  severe,  acute  or  chronic,  etc.  But 
even  in  incurable  cases,  for  example,  in  hypertrophy,  indurations, 
and  tumors  of  the  uterus;  the  symptoms  of  nervous  irritation 
may  be  so  moderated,  or  completely  subdued,  that  the  patient 
will  enjoy  excellent  health  with  great  or  entire  freedom  from 
suffering. 

Besides,  in  those  cases  of  irritable  pelvic  viscera  which  defy 
every  ascertained  mode  of  promoting  a  cure,  the  patient  may,  with 
good  reason,  entertain  the  hope  that  time  will  bring  relief;  that 
the  disease  "  will  wear  out ;"  or,  more  scientifically,  that  the  re- 
volutions continually  occurring  in  the  animal  economy,  before, 
and  especially  at  the  time  of  the  disappearance  of  the  menstrual 
function,  may  render  the  nervous  system  less  sensitive,  and  even 
diminish  the  degree  of  local  irritation.  The  woman  after  fifty, 
often,  enjoys  excellent  health,  when  life  previously  had  been 
painful  and  distressing. 


TREATMENT    OF    IRRITABLE    UTERUS.  243 


CHAPTER   IX. 

TREATMENT    OF    IRRITABLE    UTERUS— REMOVAL    OR 
PALLIATION    OF    THE    CAUSE. 

The  unavoidable  conclusions  from  tlie  facts  adduced  in  illus- 
trating the  nature  and  history  of  irritable  uterus,  are,  that  the  local 
complaint  is  primary ;  that  the  general  disturbance  of  the  cerebro- 
spinal nervous  system,  and  the  reflex  influences  on  individual 
organs,  are  altogether  secondary;  and  that  however  much  the 
predisposing  causes,  or  the  general  health  may  be  improved,  and 
the  nervous  susceptibilities  diminished  by  appropriate  general 
treatment ;  yet,  after  all,  the  patient  is  not  well.  There  is  pallia- 
tion of  suffering,  but  no  radical  relief.  Permanent  advantage 
will  not  be  gained  by  a  constant  treatment  merely  for  plethora, 
weakness,  lassitude,  ansemia,  dyspepsia,  cerebro-spinal  irritation, 
or  congestion.  We  have  known  ten,  fifteen,  and  twenty  years 
wasted,  amid  great  sufferings,  in  vain  attempts  to  give  strength 
to  the  weak,  red  blood  to  the  anaemic,  healthy  functions  to  the 
dyspeptic  and  bilious,  and  to  diminish  general  or  local  plethora 
by  evacuants  and  revulsives.  The  cause  having  been  over- 
looked, all  treatment  was  ineffectual  for  recovery,  everything 
was  but  palliative. 

On  the  contrary,  if  the  cause  be  removed ;  if  the  irritant  be 
destroyed ;  it  is  most  wonderful  how  rapidly,  sometimes  how  in- 
stantaneously, irritations  will  cease.  The  neuralgia,  the  spasms, 
the  wretched  sensations  in  the  brain,  heart,  lungs,  etc.,  will  most 
mysteriously  vanish.  A  clearness  is  imparted  to  the  mental 
vision,  the  mind  again  becomes  capable  of  thought  and  reflection; 
pleasant,  cheerful,  amiable  feelings,  succeed  the  desponding,  irri- 
table, gloomy,  despairing  sentiments  which  had  become  habitual. 
There  arises  a  feeling  of  lightness,  of  buoyancy  of  body,  mind, 
and  spirit,  to  which  the  poor  sufferer  had  long  been  a  stranger. 
The  whole  being  seems  to  be  revolutionized,  a  new  life  is  im- 
parted, a  peculiar  zest  is  given  to  the  business  and  pleasures  of 


244  TREATMENT    OF    IRRITABLE    UTERUS. 

life,  so  that  the  patient  feels  a  doubt  as  to  her  own  personal 
identity ;  so  different  are  present  from  former  sensations.  Even 
when,  as  is  usually  the  case,  the  improvement  is  more  gradual  as 
the  cause  is  slowl}^  removed,  yet  the  relief  is  often  as  decided  as 
it  is  wonderful,  "One  hundred  miserable  feelings,"  said  a  lady, 
to  the  author,  "  have  vanished  since  your  visit  of  yesterday." 


REMOVAL  OR  PALLIATION  OF  THE  CAUSE. 

The  first  indication  in  the  treatment  of  irritable  uterus  is  the 
removal  of  the  cause,  or  to  palliate  it  so  far  as  practicable.  Un- 
fortunately, there  are  cases  in  which  the  cause  cannot  be  detected; 
such  cases  are  incurable  by  the  practitioner,  however  much  he 
may  succeed  in  palliation.  In  some,  the  causes  may  be  detected 
but  cannot  be  removed;  but  generally  their  influences  can  be 
palliated ;  at  times  their  character  is  transitory,  and  they  will 
spontaneously  disappear. 

Congestions  of  the  uterus,  so  far  as  they  differ  from  inflam- 
mations, though  so  generally  regarded  as  a  cause,  are,  according 
to  views  already  presented,  the  effect,  and  need  hardly  now  be 
specially  noticed.  Let  it  be  remembered,  however,  that  in  a  few 
cases,  especially  at  the  menstrual  periods,  these  congestions  may 
be  so  great  as  to  increase  the  sufferings,  and  to  demand  some 
temporary  remedies,  before  a  radical  treatment  can  be  applied. 
They  may  thus  become  aggravating  causes ;  then,  the  application 
of  a  few  cups  to  the  sacral  region,  of  leeches  to  the  hypogastric, 
the  perineum,  or  the  labia  may  be  very  comforting  and  useful. 
These  may  be  assisted  by  laxatives,  diaphoretics,  and  especially 
by  warm  hip-baths,  fomentations,  and  poultices.  All  this,  how- 
ever, is  rarely  demanded,  and  should  be  restricted  as  much  as 
possible;  for,  few  things  are  more  injurious  than  the  persistent 
use  of  direct  evacuants  in  irritable  diseases.  This  is  in  accord- 
ance with  the  general  principle,  that  the  irritability  of  a  part,  or 
of  the  whole  economy,  is  inversely  as  the  strength. 

Acute  Inflammations  often  produce  irritability  of  the  uterus, 
and  must  therefore  be  relieved  by  the  usual  antiphlogistic  mea- 
sures.     Where,   however,  inflammatory  symptoms  have  disap- 


CHKONIC    INFLAMMATION,  245 

peared,  and  the  part  remains  merely  morbidly  sensitive  or  irrita- 
ble ;  then  the  consequences — a  very  different  set  of  phenomena — 
demand  attention.  The  irritability,  thus  the  sequel  of  inflamma- 
tion, will  often  disappear  rapidly,  providing  no  new  source  of 
irritation,  or  no  aggravating  cause  be  operative,  especially  under 
the  soothing  influence  of  rest  in  bed.  Judicious  management, 
therefore,  during  and  after  acute  inflammation,  will  soon  remove 
every  vestige  of  disease,  especially  if  the  patient  be  seen  before 
organic  changes  have  occurred. 

Chronic  Inflammation.  —  But  chronic  inflammations  are 
often  coexistent  with  irritable  uterus,  and  one  of  the  great  patho- 
logical questions  of  the  day  is  how  far  they  are  mutually  con- 
nected as  cause  and  effect.  That  inflammation,  with  its  sequela 
ulceration,  is  the  common  and  almost  universal  cause  of  nervous, 
neuralgic,  and  spasmodic  affections,  is  the  prevalent  notion  of 
pathologists  in  Europe  and  America.  Thence,  all  their  efforts 
are  directed  to  the  removal  of  the  inflammation  as  the  cause,  the 
"  radix  malorum.''''  By  the  author,  these  opinions  are  regarded  as 
fundamentally  erroneoas,  and  the  practice  resulting  as  decidedly 
mischievous.  For  although,  occasionally,  it  is  true  that  the 
chronic  inflammation  is  the  sole,  ejEficient  cause,  and  its  removal 
the  sine  qua  non  to  recovery ;  yet  in  a  large  majority  of  cases  the 
nervous  symptoms  have  an  independent  origin.  They  may  exist 
in  all  their  intensity  without,  as  well  as  with,  inflammation;  they 
often  are  present  before  inflammation  appears;  and  very  fre- 
quently they  remain  even  for  many  years  after  all  inflammatory 
symptoms  have  disappeared.  When  nervous  irritation  is  com- 
plicated with  organic  or  inflammatory  irritation  of  a  chronic 
character,  their  existence  is  very  generally  due  to  a  common 
cause. 

A  prolapsus  uteri,  for  example,  may  give  rise  to  the  symptoms 
of  irritable  uterus,  and  also  to  those  of  inflammation  of  the  cervix 
uteri.  In  this  case,  the  displacement  is  the  common  cause,  neither 
the  irritability  depending  on  the  inflammation,  nor  the  inflamma- 
tion on  the  irritation,  but  both  on  the  unnatural  position  of  the 
organ.  The  continual  pressure  on  the  displaced  womb  from  the 
weight  of  the  superincumbent  viscera,  enormously  enhanced  by 
the  contraction  of  the  muscular  parietes  of  the  abdomen,  will 
arouse  slowly  but  often  very  effectually  the  nervous  suscepti- 


246  TREATMENT    OF    IRRITABLE    UTERUS. 

bilities  of  the  whole  uterus;  while  the  constant  attrition  of  the 
delicate  tissues  of  the  os  and  cervix  uteri  against  the  posterior 
surface  of  the  vagina,  where  it  covers  the  rectum  and  perineum, 
will  frequently  produce  organic  irritation  or  inflammation.  In 
such  cases,  by  perfect  rest,  washes,  and  other  antiphlogistic  means, 
the  inflammation  may  be  readily  subdued.  But  the  moment  the 
patient  is  on  her  feet,  or  making  any  muscular  effort,  she  finds 
that  her  complaints  are  as  bad  as  ever,  because  the  irritable  con- 
dition remains  inasmuch  as  the  prolapsus  continues ;  the  irritation 
is  again  immediately  re-excited  long  before  any  recurrence  of  the 
inflammatory  symptoms. 

The  deductions  resulting,  if  these  views  be  correct,  are,  that  in 
a  comparatively  few  cases  chronic  inflammation  may  be  the  effi- 
cient cause  of  irritable  uterus ;  that  in  all  cases  it  is  an  aggra- 
vating cause;  and,  therefore,  whenever  present,  it  demands  a 
suitable  treatment  to  diminish  or  destroy  its  symptoms.  Never- 
theless a  pure  aniijjhiogistic  treatment  should  seldom  be  trusted ; 
in  a  large  majority  of  cases  it  should  be  considered  merely  as  of 
a  temporary  or  accessory  importance.  The  main  dependence 
should  be  placed  on  rest  and  remedies  for  an  irritable,  not  an 
inflamed  organ.  In  these  chronic  cases  especially,  the  perse- 
verance in  a  course  of  antiphlogistic  remedies,  whether  local  or 
general,  or  both,  will  prove  not  merely  nugatory,  but  highly 
detrimental  and  dangerous.  So  common  are  the  evils  resulting 
from  this  practice,  that  proofs  of  the  truth  of  these  opinions  are 
to  the  writer  almost  innumerable. 

Cases. — A  lady,  from  Alabama,  informed  us  that  from  the  time 
of  her  marriage,  at  the  age  of  fourteen,  she  had  been,  now  for 
some  fifteen  years,  the  subject  of  the  most  intense  pelvic  distress 
and  suffering,  by  which  she  was  completely  disabled.  The  use 
of  the  lancet,  assisted  by  low  diet,  calomel,  and  purgatives,  had 
been  carried  to  such  an  extent  that  the  greatest  possible  emacia- 
tion was  induced,  and  all  her  powers  prostrated,  so  that  for  years 
it  was  not  thought  that  she  could  possibly  recover.  At  the  bend 
of  each  arm  innumerable  cicatrices  testified  to  the  accuracy  of 
her  statement. 

A  lady,  from  Missouri,  with  a  retroverted  uterus,  and  an  atre- 
sia of  the  vagina,  had  been  copiously  bled  every  few  days  during 
three  months  for  severe  pain  and  congestion  of  the  brain,  until 


LOCAL    ANTIPHLOGISTIC    MEASURES.  2-i7 

she  became  exceedingly  anajmic,  and  her  blood  resembled  "  pink- 
colored  water,"  with  but  temporary  relief. 

A  lady,  from  Virginia,  had  been  subjected  for  six  years  to  the 
use  of  mercury,  had  been  salivated  several  times,  and  was  still 
kept  under  the  influence  of  this  drug,  for  supposed  scirrhus  of 
the  cervix  uteri.  Her  husband  stated,  no  doubt  hyperbolically, 
that  his  wife  had  taken  a  quart  of  calomel  in  six  years.  She 
speedily  recovered,  however,  under  the  treatment  for  irritable 
uterus  caused  by  retroflexion. 

Much  dependence,  especially  of  late  years,  has  been  placed  on 
local  antijjhiogistic  remedies,  which,  as  already  intimated,  are  occa- 
sionally requisite  to  moderate  severe  pain,  great  congestions,  or 
when  the  symptoms  are  urgent.  They  are  often  useful  as  tempo- 
rary or  occasional  measures.  But,  under  the  idea  that  inflamma- 
tion is  present  and  must  be  subdued,  the  practice  has  been 
continued,  even  in  the  same  case,  for  months  or  years.  Cups  to 
the  loins,  leeches  applied  to  the  vagina  and  to  the  uterus,  assisted 
often  by  scarifications  and  even  incisions  of  the  os  and  cervix 
uteri,  have  been  employed  sometimes  for  a  long  period  with 
decided  mischief  to  the  general  system,  and  very  often  an  aggra- 
vation of  the  local  symptoms.  This  is  true  even  when  some 
inflammation  is  still  existing :  but  more  especially  so,  in  those 
numerous  cases  where  no  inflammation  whatever  really  exists, 
where  the  supposed  indications  of  phlogosis  were  entirely  neu- 
ralgic and  spasmodic,  with  or  without  nervous  congestion ;  or 
where  the  chronic  inflammation  existing  was  accidental,  and  not 
essential,  secondary,  and  unimportant. 

The  same  remarks  are  applicable  to  the  inordinate  perseverance 
in  other  varieties  of  antiphlogistic  remedies.  If  a  simple,  non- 
specific inflammation  (for  no  allusion  is  now  made  to  scrofulous, 
syphilitic,  phagedenic,  cancerous,  and  other  peculiar  or  malignant 
diseases)  cannot  be  relieved  by  a  moderate  and  comparatively 
restricted  use  of  evacuants,  assisted  by  astringent  and  alterative 
remedies ;  it  certainly  ought  to  be  suspected,  that  there  must  be 
some  counteracting  agency,  some  persistence  in  the  original,  new, 
or  aggravating  cause,  some  peculiarity  of  the  patient's  general 
health,  some  sympathetic  mal-influences  from  other  tissues  and 
organs,  or,  what  is  more  frequently  the  case,  that  there  has  been 
an  entire  mistake  made  as  to  the  pathology  of  the  case.  Is  it 
conceivable,  on  any  acknowledged  principles,  or  on  any  results 


248  TREATMENT    OF    IRRITABLE    UTERUS. 

of  experience  of  the  wise  and  prudent  surgeon,  tliat,  if  a  non- 
specific inflammation  or  ulceration — the  cause  being  removed — ■ 
will  not  disappear  under  the  influence  of  mild  and  soothing  mea- 
sures, assisted  by  solutions  of  the  nitrate  of  silver,  and  occasion- 
ally by  the  judicious  and  transient  application  of  the  solid  nitrate, 
any  good  can  be  anticipated  from  repeated  and  prolonged  burn- 
ings from  the  lunar  caustic;  or,  if  this  fail,  from  the  mineral 
acids,  the  acid  nitrate  of  mercury,  chromic  acid,  the  chloride  of 
zinc,  the  potassa  pura,  the  potassa  cum  calce,  or  the  actual 
cautery?  Will  not  all  and  each  of  these  articles  produce  a  more 
intense  inflammation,  a  deeper  ulceration  than  the  original  in- 
flammation, however  intense,  or  however  prolonged  ?  What 
would  be  thought  of  the  science,  skill,  and  judgment  of  a  prac- 
titioner who  should,  in  obstinate  chronic  inflammations  and 
ulcerations  of  the  mucous  membrane  of  the  nares,  of  the  mouth, 
of  the  throat,  of  the  larynx,  of  the  eye,  or  of  the  rectum,  resort,  in 
rapid  succession,  to  the  various  grades  of  stimulating  and  caustic 
applications,  not  to  be  deterred  in  his  heroic  treatment  until  the 
red  or  the  white-hot  iron  had  done  its  fatal  work? 

Some  forty  years  ago,  the  writer  was  present  at  a  consultation 
of  three  leading  surgeons,  on  a  case  of  gangrenous  chancre  of  the 
penis,  which  had  defied  the  usual  treatment,  in  a  man  whose 
health  was  broken  down  by  disease,  mercurials,  etc.  One  ex- 
claimed, in  the  full  confidence  of  his  science  and  principles, 
"  Carthago  del enda  est,"  "there  is  no  treatment  for  syphilis  but 
mercury ;  more  calomel  must  be  given."  So  now,  for  ulcers, 
almost  if  not  altogether  invisible,  certainly  intangible,  cauteriza- 
tion after  cauterization,  each  more  severe  than  its  predecessor,  is 
said  to  be  the  only  remedy  for  obstinate  inflammation  and  ulcera- 
tion of  the  uterus !  No  apparent  attention  is  paid  to  the  original 
or  accessory  causes,  to  the  peculiar  condition  of  the  surrounding 
organs.  The  answer  made  to  all  such  objections,  although  they 
are  perfectly  in  accordance  with  experience  in  other  organs,  is, 
that  the  patients  recover.  This  may  be,  and  doubtless  is,  some- 
times true;  but,  in  numerous  cases,  the  whole  theory  and  prac- 
tice is  a  failure.  Patients  are  constantly  brought  here  from 
distant  parts  for  treatment  of  complaints  of  the  uterus,  still  per- 
sisting, sometimes,  in  an  aggravated  form,  where  these  remedies 
had  been  employed  for  a  long  time  in  vain. 

That  patients  will  not  only  survive  such  practice,  but  occa- 


CAUTERIZATION.  249 

sionally  recover,  is  by  no  means  wonderful  to  tlie  scientific  and 
experienced  accoucheur.  The  uterus  itself  is  not  a  vital  organ. 
All  its  inflammations,  all  its  hypertrophies,  its  indurations,  its 
tumors,  when  not  specific,  may  be  often  tolerated  for  a  long  life, 
and  may  never  prove  the  cause  of  death.  The  severe  contusions, 
lacerations,  and  the  consequent  inflammations,  ulcerations,  and 
even  gangrene  resulting  in  many  cases  of  difficult  labor,  seldom 
destroy  life.  Even  specific  diseases,  the  phagedenic  and  can- 
cerous ulcers,  with  their  fungous  growths,  their  profuse  sanies, 
fetid  and  hemorrhagic  discharges,  often  continue  for  months  and 
years,  before  relief  is  found  in  the  grave.  It  is  therefore  alto- 
gether credible,  that  however  severe  the  inflammation,  ulceration, 
and  sloughing,  produced  by  caustics,  nevertheless,  as  soon  as  the 
practitioner  shall  remit  his  so-called  remedial  applications,  the 
inflammation  will  subside,  the  sloughs  will  separate,  granulations 
form,  and  cicatrization  ensue,  and  the  patient  be  assured  of  her 
recovery.  May  not  the  question  be,  however,  seriously  and  con- 
scientiously propounded,  whether  in  all  cases  of  inflammation 
with  or  without  ulceration  of  the  mucous  membrane  of  the  cervix 
uteri,  all  this  treatment,  even  if  successful  eventually,  is  not  only 
unnecessary,  but  positively  an  aggravation  and  prolongation  of 
her  sufferings,  corporeal  and  mental?  Every  one  must  give  their 
testimony  from  their  own  experience.  The  writer  gives  his  posi- 
tively. Such  inflammations  are  as  curable  as  those  of  the  rectum, 
the  mouth,  or  the  eye,  and  by  remedies  as  mild,  as  soothing,  and 
as  effectual  in  the  one  case  as  in  the  other.  By  the  heroic  plan, 
more  suffering  is  induced,  more  time  is  required,  and  more  injury 
results  to  the  general  health  from  the  greater  suffering  and  pro- 
longed confinement ;  very  frequently,  as  intimated,  no  relief  is 
afforded — indeed,  positive  mischief,  in  many  instances,  is  inflicted ; 
the  neck  of  the  uterus  is  deformed,  the  canal  contracted,  the 
OS  uteri  almost,  if  not  quite,  impervious.  The  symptoms  of  irri- 
table uterus  often  continue,  sometimes  in  an  aggravated  form,  and 
still  worse,  according  to  the  confessions  of  most  of  these  opera- 
tors, the  inflammation  excited  by  the  knife,  or  the  caustics,  has 
penetrated  through  the  parietes  of  the  uterus  to  its  investments. 
Hence,  pelvic  cellulitis  or  peritonitis,  with  all  its  severe,  dan- 
gerous, and  even  fatal  consequences,  has  ensued.  Such  results 
the  author  has  never  had  the  misfortune  to  witness ;  he  records 
them  upon  the  testimony  of  others,  as  the  sequence  of  their  own 


250  TREATMENT    OF    IRRITABLE    UTERUS. 

operation,  or  that  of  their  friends.  Certainly,  the  danger  ought 
not  to  be  incurred  for  any  common  or  healthy  inflammation,  or 
even  hypertrophy  of  the  cervix  uteri,  where  no  specific  disease 
is  present. 

Enlargements, — The  question  in  abeyance  is,  perhaps,  in 
appearance  at  least,  altered,  when  there  is  a  permanent  enlarge- 
ment of  the  cervix  uteri ;  in  other  words,  in  cases  of  hypertrophy 
or  induration  of  the  neck  of  the  uterus. 

The  distinction  has  already  been  drawn  between  hypertrophy 
and  simple  induration.  The  former  is  usually  the  result  of  simple 
congestion,  the  latter,  of  inflammation.  Examples  of  the  former 
are  seen  in  pregnancy  and  cases  of  polypi;  it  is  simple  develop- 
ment, growth,  with  no  alteration  of  tissue,  "proliferation  of 
tissue,"  as  termed  by  M.  Klob.  The  latter  all  are  familiar  with, 
as  the  result  of  metritis. 

Hypertrophy. — In  hypertrophy,  where  no  phlogosis  has  been  or 
is  present,  is  it  conceivable  that  cauterization  is  requisite  to  dimi- 
nish or  destroy  the  enlargement?  What  practitioner  would  be 
regarded  as  ^^  compos  mentis^''''  who  should  resort  to  his  cauteries 
for  the  hypertrophy  resulting  from  a  polypous  tumor  or  from  a 
foetus  in  utero?  Yet,  what  is  the  difference  in  hypertrophies 
arising  from  other  causes?  Tn  both  there  is  simple  enlargement, 
development;  and  in  both,  there  is  no  inflammation,  and,  indeed, 
no  morbid  organic  action.  In  each  there  must  be  a  cause  of  such 
increased  growth.  In  the  former,  the  polypus  or  the  foetus  being 
removed,  the  enlargement  disappears.  Is  it  then  not,  therefore, 
a  natural  conclusion,  that  in  the  latter  also,  the  detection  and  the 
removal  of  the  cause  would  be  a  far  more  rational  practice  than  the 
application  of  the  potential  or  actual  cautery?  Yet  the  hyper- 
trophy is  often  spoken  of  as  the  disease,  ^^ipse  morbus;''''  it  must 
be  destroyed ;  and  nothing  else  is  thought  of  as  necessary  or 
practicable. 

Again,  even  if  the  cause  be  removed  and  the  hypertrophy  con- 
tinues, or  at  least  disappears  very  slowly,  on  what  therapeutical 
principles  can  the  caustic  treatment  be  justified?  Would  it  not 
be  substituting  a  greater  evil  for  a  less — a  state  of  inflammation, 
suppuration,  ulceration,  and  gangrene,  for  a  simple  increased  or- 
ganic action,  which  is  not  truly  abnormal  even  when  great  deve- 
lopment occurs,  but  normal,  natural?  Will  not  the  tissues,  thus 
excited  and  irritated  to  a  morbid  state,  be  far  more  likely  to  re- 


INDURATION".  251 

main  permanently  enlarged  by  the  inflammatory  process  thus 
induced  by  the  stimulating  and  caustic  applications  ?  Might  it 
not  be  rationally  expected  that  the  increased  size  would  more 
certainly  and  safely  disappear  by  quieting  irritations  and  pro- 
moting the  secretions  by  the  use  of  warm  baths  and  fomentations, 
by  warm  mucilaginous  vaginal  injections,  by  emollient  ointments, 
by  the  various  applications  of  conium,  belladonna,  and  other 
narcotics,  by  mercurial,  iodine,  and  other  resolvents  ? 

The  appeal  made  by  its  advocates  to  the  results  of  this  caustic 
practice  is  certainly  not  satisfactory.  There  have  been  no  com- 
parative trials  made  of  the  two  modes  of  treatment ;  no  candid 
statement  of  the  bad  as  well  as  of  the  apparently  favorable  results 
of  the  caustic  method.  Few,  perhaps  very  few,  practitioners 
have  acted  on  the  principle  of  removing  the  cause  of  hypertrophy. 

Many  cases  of  reported  success  may  be  explained  by  the  fact 
that  the  caustics,  so  called,  have  not  been  used  as  caustics,  but  so 
slightly  applied,  or  so  diluted,  as  to  act  merely  as  stimuli,  or  as 
resolvents.  Thus  we  hear  of  the  "  antiphlogistic"  touch  of  the 
nitrate  of  silver. 

Such  "touches,"  or  the  application  of  weak  solutions  of  the 
nitrate  of  silver,  the  persevering  employment  of  the  tincture  or 
other  preparations  of  iodine  to  the  neck  of  the  uterus,  or  the  use 
of  various  medicated  vaginal  suppositories  may  be  all  very  influ- 
ential in  diminishing  the  hypertrophied  condition  of  the  organ. 
It  is  very  difficult,  however,  to  give  credence  to  the  theory  that 
powerful  caustics  tend,  notwithstanding,  the  acute  inflammation 
excited,  to  promote  absorption. 

Induration. — Very  similar  questions  and  answers  may  be  asked 
and  given  as  to  the  treatment  of  induration  by  the  same  heroic 
remedies.  The  two  cases,  of  hypertrophy  and  induration,  although 
different  as  to  their  causes,  the  actual  condition  of  the  tissues,  and 
their  susceptibility  to  remedial  influences,  are,  nevertheless,  very 
similar  as  to  the  bad  consequences  which  may  result  from  such 
applications,  and  as  to  the  means  of  preventing  and  relieving 
such  evil  effects. 

The  condition  now  to  be  considered  is  that  of  the  cervix  indu- 
rated and  enlarged  by  lymphatic  deposits,  the  result  of  phlogosis. 
It  has  ceased  to  be  an  inflammatory  state ;  inflammation  has  dis- 
appeared, but  its  effects  remain.  An  anchylosed  joint  is  a  similar 
condition,  and  may  remain  for  years,  or  even  for  life,  as  the  result 


252  TREATMENT    OF    IRRITABLE    UTERUS. 

of  an  inflammatory  disease.  Every  one  is  familiar  with,  the  in- 
durated condition  of  the  mammary  gland,  which  remains  for  a 
long  time  after  all  symptoms  of  phlogosis  have  terminated.  Also, 
an  indurated  neck  or  body  of  the  uterus  may  continue  after  all 
morbid  excitement  has  completely  disappeared.  In  such  cases, 
it  is  difficult  to  perceive  how  cauterization  can  be  justified.  In- 
flammation of  a  simple,  non-specific  character,  produced  the  in- 
duration ;  inflammation  was  the  cause.  Why  then  reproduce  an 
inflammation  by  caustics  ?  Just  in  proportion  to  the  degree  of 
inflammation  re-excited  will  be  the  probability  of  increased  indu- 
ration; provided,  always,  the  tissues  are  not  destroyed  by  ulcera- 
tion and  gangrene.  The  plea  that  resolution  is  expected  from 
this  practice  may  be  satisfactory  to  the  inexperienced,  but  not  to 
the  experienced  practitioner.  Indurations  of  the  mammae,  the 
lips,  ears,  and  other  portions  of  the  economy  are  not  thus  treated 
by  surgeons,  and  for  what  reason  indurations  of  the  neck  of  the 
uterus  either  demand  or  can  be  profited  by  such  practice  yet  re- 
mains to  be  shown. 

The  truth,  as  it  seems  to  be  supported  by  reasoning,  and  by 
the  experience  of  the  writer  at  least,  is,  that  in  hypertrophied  and 
indurated  states  of  the  cervix,  when  the  original  cause  is  no 
longer  operative,  there  is  really  no  disease.  The  patient  not  only 
is,  in  current  professional  language,  well,  but  feels  well,  so  long 
as  she  remains  quiet  in  the  recumbent  position ;  yet  as  soon  as 
she  rises,  and  makes  any  muscular  effort,  the  supports  of  the 
uterus  show  that  they  are  not  equal  to  the  increased  weight 
thrown  upon  them,  and  this  enlarged  and  heavy  viscus  presses 
firmly  against  the  floor  of  the  pelvis.  The  uterus  becomes  pro- 
lapsed, or,  it  may  be,  retroverted,  and  then  follow  sensations  of 
pressure,  fulness,  and  weight,  which  in  turn  are  succeeded  by 
soreness,  pain,  and  all  the  tribe,  perhaps,  of  the  symptoms  of 
irritable  uterus,  symptoms  due  to  displacement,  and  not,  as  gene- 
rally referred,  to  congestions  and  inflammations.  This  mistake  is 
the  more  readily  made  in  the  present  instance,  as  actual  indura- 
tion is  present.  In  all  such  cases,  it  is  not  the  antiphlogistic,  or 
the  cauterizing  treatment,  which  is  demanded,  but  suitable  mea- 
sures for  removing  and  preventing  displacement.  Thus  the  feel- 
ings of  pressure,  soreness,  and  pain,  may  be  dissipated,  and  the 
way  be  prepared  for  the  employment,  with  far  more  rational 
hope  of  success,  of  the  usual  resolvents,  such  as  iodine,  nitrate 


RHEUMATIC    OR    GOUTY    IRRITATION".  253 

of  silver,  etc.  Much  experience  enables  the  author  to  affirm  that, 
even  when  the  induration  continues,  the  patients  will  often  feel 
perfectly  comfortable  and  enjoy  life  as  much  as  ever.  Under  this 
treatment,  however,  indurations  will,  in  many  instances,  gradually 
but  regularly  disappear. 

General  Conclusions. — The  conclusions,  therefore,  which 
may  be  safely  made  from  this  discussion,  are — 

1st.  In  all  cases  of  acute  inflammation,  perfect  rest  in  bed,  with 
appropriate  antiphlogistic  remedies,  should  be  exclusively  relied 
upon. 

2d.  In  chronic  inflammation,  with  nervous,  neuralgic,  and 
spasmodic  symptoms,  while  constant  attention  should  be  paid  to 
the  phlogosis,  the  main  business  of  the  practitioner  has  respect  to 
the  nervous  irritation.  This  usually  has  a  distinct  origin,  and  is 
thus  far  independent  of  the  inflammation.  The  latter  may  be, 
and  often  is,  an  aggravating,  but  not  the  essential  cause.  It  may 
be  removed,  and  the  nervous  irritation  will  continue  in  all  its 
intensity. 

3d.  The  persistence  in  the  antiphlogistic  treatment,  especially 
by  heroic  remedies,  powerful  stimulating  and  caustic  revulsives, 
is  founded  on  a  wrong  principle,  and  is  calculated  to  increase, 
rather  than  to  diminish  the  morbid  irritability  of  the  tissues. 

4th.  By  a  careful  attention  to  the  various  predisposing  and 
exciting  causes  of  inflammation,  and  by  mild  and  soothing  mea- 
sures, more  will  be  accomplished  than  by  a  resort  to  powerful 
and  destructive  escharotics. 

5th.  Hypertrophied  and  indurated  enlargements  of  the  uterus 
are  usually  injurious  merely  from  their  size  and  weight.  Hence 
patients  at  rest  are  often  perfectly  comfortable,  but  in  motion, 
become  tormented  by  the  symptoms  of  di.^placed  and  irritable 
uterus. 

6th.  And  therefore  suitable  pessaries,  not  caustics,  are  generally 
the  proper  means  for  palliation,  and  even  for  radical  recovery. 

Eheumatic  or  Gouty  Irritations. — When  symptoms  of 
irritable  uterus  are  connected  with  rheumatic,  gouty,  or  other 
irritat'ons  of  a  metastatic  character,  the  peculiar  treatment  for 
such  complaints  may  be  rigidly  enforced  in  all  acute  cases,  both 
as  a  palliative  and  preventive  treatment  for  the  irritable  symp- 
toms; but  in  chronic  cases,  great  care  is  demanded  in  the  diag- 


254:  TREATMENT    OF    IRRITABLE    UTERUS. 

nosis,  and  in  determining  wliat  other  causes  are  operative  and 
how  they  are  to  be  removed.  For,  many  cases  of  supposed 
rheumatic  affections  of  the  uterus  depend  on  displacements  or 
some  other  irritating  cause. 

Parturient  State. — The  predisposing  influences  of  gestation 
and  parturition  are  always  to  be  regarded,  and,  as  far  as  possible, 
moderated,  so  as  to  prevent,  or  to  ameliorate  the  symptoms  of 
irritable  uterus.  In  this  point  of  view,  perfect  rest,  the  avoid- 
ance of  all  sources  of  irritation  to  the  uterus,  and  the  judicious 
resort  to  soothing  and  anodyne  treatment,  after  labor,  are  not 
merely  advisable,  but  actually  necessary,  until  the  symptoms  of 
nervous  irritation  and  engorgement,  which  then  always  exist,  in 
a  less  or  greater  degree,  be  entirely  dissipated.  This  injunction 
of  perfect  rest  in  a  recumbent  position,  and  the  avoidance  of  all 
muscular  effort,  in  turning,  in  urination,  and  in  defecation,  is  all 
important,  until  the  uterus  has  gradually  returned  to  its  normal 
size  and  weight ;  and  the  ligaments  and  other  tissues,  elongated 
during  pregnancy,  have  contracted  to  their  natural  length,  and 
acquired  their  usual  strength.  Then,  the  displacements  of  this 
organ,  so  frequently  resulting,  after  confinements,  from  premature 
erect  postures  and  muscular  efforts,  would  often  be  prevented ; 
and,  therefore,  also  those  wretched  nervous  disturbances,  which 
torment  so  many  women  for  years,  succeeding  a  labor,  would  be 
less  frequent.  Thus,  to  prevent  displacements  and  to  obviate 
any  predisposition  to  local  or  general  nervous  affections,  perfect 
rest  and  soothing  treatment  are  essential ;  but  after  almost  every 
labor,  this  practice  is  still  more  important  to  prevent  organic 
irritation,  i.e.,  inflammation  of  the  vagina,  uterus,  ovaries,  peri- 
toneum, etc. 

Lactation. — The  obstetric  practitioner  must  also  watch  care- 
fully (especially  when  his  patient  has  been  brought  up  amidst  the 
refinements  and  luxuries  of  civilized  life)  the  effect  of  lactation  on 
the  nervous  system,  and  particularly  on  that  of  the  uterus.  He 
should  enforce  attention  to  the  rule,  that  no  woman  who  becomes 
more  and  more  pallid,  more  and  more  exhausted,  or  more  and 
more  nervous,  ought  to  persevere  in  nursing  her  infant.  This  rule 
becomes  the  more  imperative  when  nervous  headaches  begin,  and 
continue  to  increase  in  frequency;  when  any  symptoms  of  croup, 


INDULGENCE    OF    THE    APPETITES.  255 

asthma,  palpitation  of  the  heart,  gastrodynia,  colic,  uterine  neu- 
ralgia or  spasms,  are  superadded  to  the  ordinary  symptoms  of 
nervous  distress.  It  should  be  enforced  under  these  circum- 
stances, even  when  the  mother  has  a  large  supply  of  nutriment 
for  her  infant.  The  increased  flow  of  milk  from  the  mammae 
aggravates  the  debility  and  the  irritability  of  the  patient,  par- 
ticularly in  all  instances  where  the  appetite  for  food  is  dimin- 
ished or  lost.  This  continual  drain,  where  there  is  no  adequate 
replenishing  process,  may  speedily  exhaust  not  merely  the  pow- 
ers of  animal  life,  but  those  also  of  organic  life,  with  terrible, 
even  fatal  consequences.  However  desirable  it  is  that  every 
woman  should  nurse  her  own  offspring  as  long  as  practicable, 
great  attention  should  be  paid,  that  no  undue  sacrifice  of  comfort 
or  health  be  made  by  the  devoted  and  self-denying  parent. 

Indulgence  of  the  Appetites. — In  preventing  irritable  and 
nervous  diseases,  the  practitioner  must  carefully  enforce  the  laws 
of  temperance  and  moderation  in  all  the  pleasures  of  sense. 

Over-indulgence  in  the  jjleasures  of  the  tahle,  as  regards  eating 
as  well  as  drinking,  is  a  most  prolific  source  of  mischief  to  the 
nervous  system.  This  is  especially  true  in  respect  to  females, 
whose  sedentary  habits  do  not  favor  the  various  secretions  and 
excretions  of  the  economy,  and  whose  digestive  functions  are 
therefore  frequently  disturbed.  They  should  adhere  to  the  rule 
that  the  quantity  and  quality  of  the  food  ought  to  be  proportioned 
to  the  degree  of  muscular  effort  daily  made.  They  should  not  in- 
dulge in  the  minor  luxuries  of  the  table,  or  acquire  morbid  tastes 
or  fancies,  to  the  destruction  of  a  normal  appetite.  In  this  way, 
they  may  avoid  dyspepsia,  torpor  of  the  liver,  and  of  the  bowels, 
and  all  the  well-known  evils  thence  resulting  to  the  organic  and 
animal  functions.  The  importance,  therefore,  of  a  well-regulated 
diet,  especially  for  young  and  growing  girls,  is  of  the  utmost 
importance.  It  should  be  nutritious,  but  not  stimulating ;  easy 
of  digestion,  and  taken  at  regular  periods.  It  is  well  to  begin 
early  in  the  morning,  and  repeat  at  intervals  of  not  more  than 
four  hours  during  the  day,  and  twelve  hours  during  the  night. 
Attention  to  these  hints  by  parents,  teachers,  and  guardians  of 
youth  in  America,  at  least,  would  prove  of  great  value  to  their 
young  and  thoughtless  proteges,  by  preventing  much  acute  dis- 


256  TREATMENT    OF    IRRITABLE    UTERUS. 

ease,  as  well  as  the  prolonged  agonies  of  a  dyspeptic  and  nervous 
patient. 

In  preventing  and  especially  in  removing  the  causes  of  irritable 
uterus,  and  of  nervous  affections,  not  merely  over-indulgence  in 
the  pleasures  of  the  table  demands  attention,  but  all  the  natural 
propensities  and  apjjetences  of  the  economy.  No  organ,  no  appa- 
ratus, and  no  system,  should  be  prematurely  or  inordinately 
excited.  There  is  a  natural,  regular,  and  healthy  development 
of  the  organs  and  of  their  functions,  which  conduces,  in  their 
due  indulgence,  to  the  welfare  and  perfection  of  the  entire  being ; 
but,  when  prematurely  developed,  or  unduly  indulged,  they  are 
proportionally  detrimental.  These  observations  apply  with  great 
force  to  those  sentiments  and  passions  which  are  unconsciously 
developed  at  the  age  of  puberty.  Hence,  all  unnatural  excita- 
tions, local  or  general,  physical  or  moral,  which  directly  or  indi- 
rectly hasten  the  premature  development  of  the  generative  organs 
and  functions,  are  most  pernicious.  The  precocious  gratification 
of  these  passions  in  the  young,  or  the  inordinate  indulgence  of 
them  at  riper  years,  are,  as  formerly  stated,  the  fruitful  source 
of  debility  and  morbid  irritability  of  the  uterus  and  the  whole 
cerebro-spinal  system.  All  that  tends  to  produce  this  condition 
must  be  resisted  and  destroyed  if  practicable.  Parents  and  guard- 
ians should  be  cautioned  as  to  the  habits  and  practices  of  their 
interesting  charge,  as  to  their  companions,  their  social  intercourse, 
their  conversation,  their  readings,  and  their  amusements ;  so  that 
while  every  opportunity  is  afforded  for  the  healthy  development 
of  the  economy,  there  should  be  no  inordinate  excitement  of  the 
feelings,  sentiments,  and  passions,  by  improper  companionship, 
and  conversation,  by  reading  works  of  imagination,  as  novels, 
romances,  plays,  by  attendance  on  balls,  theatres,  operas,  etc.;  all 
of  which,  by  this  undue  excitation,  hasten  the  development  of 
the  nervous  system,  and  the  phenomena  of  puberty,  before  the 
organic  system  is  proportionally  matured.  If  the  danger  at  this 
age  be  avoided,  the  same  excitants,  even  when  maturity  has 
arrived,  will  often  break  down  the  powers  of  life,  and  thus  give 
rise  to  the  whole  tribe  of  dyspeptic  and  irritable  disorders. 

The  practitioner  should  bear  in  mind  how  all  these  evils  are 
enhanced  by  the  sedentary  occupations  and  luxurious  indulgences 
of  civilized  life. 


DISPLACEMENTS    OF    THE    UTERUS.  257 

Excitement  of  the  Mind. — The  physician  should  place  his 
veto  also  on  the  common  practice  of  over-stimulation  of  the  mental 
powers,  however  purely  intellectual  such  stimuli  may  be.  He 
must  insist  on  moderation  in  study,  as  all  mental  and  moral  excita- 
tions are  virtually  stimuli  to  the  brain  as  a  physical  organ  and 
the  centre  of  nervous  influence.  Debility,  exhaustion,  irritability, 
and  even  collapse  of  the  nervous  system,  too  frequently  ensue  on 
a  too  early  or  continued  employment  of  the  mental  powers. 

"  Precocity  was  my  ruin,"  said  a  gentleman  of  most  excellent 
character,  but  whose  life  had  been  apparently  unproductive  of 
what  it  had  promised.  "  I  was  prepared  for  college  at  eleven ;  gra- 
duated at  fifteen ;  at  eighteen  made  my  maiden  speech  at  the  bar 
with  much  eclat;  and  then  collapsed."  How  many  parents,  after 
the  expenditure  of  time  and  money  upon  their  daughters'  educa- 
tion, with  the  terrible  sacrifices  of  domestic  intercourse,  have  to 
mourn  over  the  broken  health,  the  impaired  constitutions,  per- 
haps the  premature  death  of  their  children,  from  over-stimulation 
of  the  mental  faculties,  and  neglect  of  their  physical  being. 

Cold. — The  indirect  effect  of  cold  in  disturbing  the  functions 
of  the  uterus,  or  in  exciting  congestion  or  inflammation,  must  be 
also  carefully  counteracted  by  regulating  the  amount  of  clothing 
in  strict  accordance  with  changes  of  temperature. 

Displacements  of  the  Uterus  are,  however,  the  most  fre- 
quent cause,  original  or  secondary,  of  irritable  uterus.  Their 
complete  removal  by  measures  which  do  not  in  themselves  cause 
irritation,  is  the  most  efficient  and  sometimes  the  sole  mode  of  re- 
lief. The  causes  of  displacement,  the  varieties  and  modifications, 
the  various  modes  of  relief,  with  the  principles  which  should  re- 
gulate their  administration,  must  therefore  be  fully  studied  and 
comprehended,  if  success  be  expected  in  the  treatment  of  most 
cases  of  irritable  uterus. 

We  have  already  alluded  to  the  effect  of  pregnancy  and  partu- 
rition in  predisposing  to  or  bringing  on  such  displacements ;  and 
attention  has  been  directed  to  all  the  bad  influences  of  muscular 
effbrtj  in  whatever  way  exerted,  in  causing  irritable  uterus,  either 
directly  or  indirectly,  by  inducing  displacements  of  the  organ. 
Hence  the  necessity  of  guarding  patients  as  regards  inordinate 
muscular  effort,  not  merely  as  to  running  and  jumping,  but  as  to 
17 


258  TREATMENT    OF    IRRITABLE    UTERUS. 

dancing,  ascending  heights,  straining  in  vomiting,  coughing,  de- 
fecation, etc.  Attention  should  be  fixed  upon  the  ill  effects  re- 
sulting from  external  pressure  due  to  the  use  of  corsets,  tight 
dresses,  braces,  and  abdominal  supporters ;  so  that  care  may  be 
taken  that  no  pressure  is  made  upon  the  abdominal  viscera  in  any 
way. 

The  practitioner  must  endeavor  to  obviate,  as  far  as  practicable, 
the  effects  of  internal  pressure  and  weight.  He  must  strive  to 
dissipate  any  tympanites,  ascites,  feculent  accumulations,  mesen- 
teric, ovarian,  and  other  abdominal  tumors.  He  must  counteract, 
if  possible,  the  unavoidable  disposition  of  the  uterus  to  become 
prolapsed  whenever  its  size  or  weight,  from  any  cause,  is  aug- 
mented ;  as  in  all  cases  of  hypertrophy  of  the  organ,  of  physome- 
tra,  hydrometra,  of  retained  menses,  of  abscesses,  of  simple  indu- 
ration of  the  organ,  or  all  enlargements  connected  with  organic 
diseases,  as  tumors  within  the  cavity  or  in  the  substance  of  the 
uterus. 

Sympathetic  Disturbances. — Much  general  knowledge  and 
practical  acumen  will  be  demanded  to  trace  out  and  to  obviate 
all  those  innumerable  sources  of  mischief,  whether  original  or 
secondary,  which  symjjathetically  disturb  the  uterine  sensibilities. 
All  mental  and  moral  agitations  are  to  be  quieted  as  far  as  possi- 
ble. All  excitations  from  the  physical  condition  of  the  brain, 
spinal  cord,  lungs,  heart,  liver,  stomach  and  bowels,  must  receive 
due  and  constant  attention ;  even  when  such  visceral  disturb- 
ances were  originally  excited  by  the  uterus,  as  there  is  always  a 
mutual  action  and  reaction.  Tympanitic  states  of  the  stomach 
and  bowels,  for  example,  are  exceedingly  distressing  in  uterine 
irritations,  and  must  be  palliated  or  obviated,  as  far  as  possible. 
Yet  it  is  true  that  this  gaseous  accumulation,  very  frequently,  is 
the  result  of  the  uterine  affection.  If  the  pelvic  excitement  dis- 
turbs the  digestive  functions,  this  disturbance  aggravates  the 
pelvic  affection.  So  also,  if  the  uterus  provokes  a  nervous,  spas- 
modic cough ;  the  coughing  greatly  enhances  the  uterine  irrita- 
tion. This  is  true,  indeed,  of  all,  or  nearly  all  of  the  reflex  influ- 
ences. 

General  Remarks. — The  fulfilment  of  this  first  indication, 
iJie  removal  of  the  cause^  as  already  intimated,  is  all  important  in 


GENERAL    REMARKS.  259 

the  treatment  of  irritable  diseases.  It  is  the  ^^  sine  qua  non.^^ 
Without  this  being  accomplished,  all  other  treatment  is  but  pal- 
liative in  a  large  majorit}'-  of  cases.  However  much  may  be  done 
to  restore  strength,  to  give  rich  blood  to  the  anaemic,  or  to  quiet 
nervous  irritation,  all  will  be  but  partially  successful.  In  most 
instances,  the  patient  will  remain  obstinately  dyspeptic  or  anae- 
mic, will  complain  of  feelings  of  debility  and  exhaustion,  and  be 
tormented  with  wretched  nervous  feelings,  with  neuralgia,  spasms, 
or  even  convulsions.  Often,  also,  as  already  maintained,  this  whole 
tribe  of  nervous  irritations,  local  and  general,  will  exist  in  the 
utmost  intensity,  even  when  the  organic  actions  are  perfect,  and 
when  great  muscular  power  exists,  and  the  richest  blood  permeates 
the  system,  to  give  a  due  stimulus  to  every  function. 

In  all  such  cases,  the  treatment  demanded  for  the  removal  of 
the  cause,  is  all  that  is  required  for  the  recovery  of  the  patient. 
The  cause  being  removed,  the  patient  is  well.  She  can  and  does 
at  once  return,  not  only  to  her  natural  sensations,  but  to  her  ordi- 
nary avocations.  There  is  a  most  wonderful  and  rapid  transition 
from  extreme  suffering,  and  apparently  most  serious  disease,  to 
perfect  comfort  and  health. 


260  TREATMENT    OF    IRRITABLE    UTERUS. 


CHAPTER    X. 

TREATMENT   OF   IRRITABLE   UTERUS  — Continued.     TO   DIMIN- 
ISH   OR    DESTROY    THE   MORBID    IRRITABILITY. 

There  are,  however,  numerous  cases  in  whicli — from  natural 
temperament,  from  acquired  predispositions,  from  the  combined 
influences  of  pain,  miserable  feelings,  and  confinement  too  often 
in  close  unventilated  apartments,  from  sedentary  occupations, 
loss  of  appetite,  nausea,  and  the  whole  train  of  dyspeptic  ills — 
the  patient  is  really  debilitated,  not  merely  as  regards  her  sensa- 
tions, but  there  is  a  loss  of  power,  as  respects  the  organic  and 
animal  life.  She  may  be  anaemic,  sometimes  chlorotic,  and  inca- 
pable of  any  mental  or  physical  effort.  As  an  almost  necessary 
consequence,  she  is  irritable,  nervous,  excitable ;  the  merest  trifle, 
the  slightest  mental  or  bodily  disturbance  produces  inordinate 
effects.  A  degree  of  uterine  irritation,  which,  in  a  large  propor- 
tion of  v/omen  would  be  disregarded,  will,  in  such  sensitive  per- 
sons, excite  much  distress,  and  call  for  much  attention. 

In  all  such  cases,  there  is  a  second  indication  to  be  fulfilled, 
namely,  to  diminish  or  destroy  the  morbid  irritability,  whether 
general  or  local. 

As  already  intimated,  all  measures  will  be  but  palliative  until 
the  cause  be  removed,  though  much  may  be  anticipated  from 
judicious  management.  The  presumption  now  made  is,  there- 
fore, that  the  cause  is  no  longer  operative ;  or,  in  other  words, 
that  there  is  no  inflammation,  no  rheumatic,  or  gouty  irritation 
of  the  uterus ;  no  ovarian,  rectal,  or  vesical  irritation ;  no  sympa- 
thetic disturbance  of  the  uterus  from  other  organs;  no  displace- 
ments from  simple  relaxation  or  elongation  of  the  ligaments, 
from  hypertrophy  or  induration  of  this  organ,  or  from  the  pre- 
sence of  internal  or  external  tumors. 

Then,  since  no  exciting  cause  remains,  the  morbid  sensitive 
state  of  the  patient  may  be  moderated  or  relieved  by  direct  or 
indirect  measures. 


DIRECT    AND    INDIRECT    MEASURES.  261 

The  former  inclacles  all  those  remedial  agents  which  have  a 
direct  sedative  or  anodyne  influence  on  the  nervous  system,  par- 
ticularly the  antispasmodic  and  narcotic  medicines,  so  useful  as 
temporary  means  in  assuaging  pain  and  moderating  miserable 
nervous  sensations.  These  are  valuable  as  palliative  measures, 
but  seldom  useful  as  permanent  remedies. 

Every  one  is  acquainted  with  the  use  and  the  abuse  of  narco- 
tics— how  delightful  they  are  to  most  persons,  especially  when 
tormented  by  pain  or  by  those  indescribable  wretched  feelings, 
which  annoy  the  nervous  patient  by  night  as  well  as  by  day. 
The  temptation  to  indulgence  is  great  and  often  unconquerable. 
Let  it,  however,  never  be  forgotten  that  no  permanent  benefit 
results.  They,  indeed,  wear  out  the  nertous  power ;  larger  doses 
are  demanded  to  obtain  relief;  and  every  day  the  poor  patient 
becomes  more  nervous,  and  more  susceptible  to  any  morbid  im- 
pression. Mind,  as  well  as  body,  becomes  more  prostrate,  and  a 
useless,  wretched  life  is  often  followed  by  a  premature  death. 

These  observations  also  apply,  be  it  remembered,  to  the  com- 
mon resort  to  alcoholic  stimuli  by  nervous  sufferers.  The  feel- 
ings of  lassitude,  of  debility,  and  exhaustion,  the  sensations  of 
sinking  and  emptiness,  of  fainting,  even  the  severe  neuralgic 
and  spasmodic  pain,  are  all  temporarily  relieved  by  spirituous 
potations.  When  united  with  hot  water,  they  are  very  valuable 
to  relieve  all  these  sensations,  especially  as  they  act  so  well  as 
carminatives.  Alcohol  becomes,  therefore,  a  most  important 
adjuvant  to  our  other  antispasmodic  remedies;  but  the  abuse  of 
it,  even  by  intelligent  and  refined,  by  moral  and  spiritual  women, 
has  been  terrible.  The  disease  is  not  removed,  though  the  tem- 
porary relief  is  great ;  a  bad  habit  is  created,  and  the  dire,  uncon- 
trollable consequences  of  confirmed  intemperance  are  too  often 
witnessed  by  sympathizing  friends.  So  many  fine  women,  of 
great  mental  and  moral  endowments,  calculated  to  adorn  and 
bless  society,  have  been  thus  wrecked,  that  the  practitioner  of 
medicine,  while  he  is  justified  in  the  temporary  employment  of 
such  stimuli,  should  utter  a  constant  warning  against  their  abuse, 
and  devote  all  the  energies  of  his  mind,  and  all  the  resources  of 
science,  to  eradicate  the  evils  which  constitute  the  pretext  for 
these  pernicious  indulgences.  The  inhalation  of  ether  and  chlo- 
roform may,  in  extreme  cases,  be  resorted  to  by  the  practitioner  • 
patients  themselves  and  their  friends  should  never  employ  anses- 


262  TREATMENT    OF    IRRITABLE    UTERUS. 

thesia.  There  have  been  too  many  records  of  persons  found 
dead  after  the  secret  resort  to  these  agents ;  and,  in  all  cases, 
the  same  objections  to  their  use  may  be  urged  as  in  the  case 
of  alcohol  or  opium ;  they  effect  no  permanent  good,  but  are 
rather  detrimental. 

The  second,  or  the  indirect  mode  of  treatment,  is  far  more  effi- 
cient, although  less  immediately  advantageous,  and  constitutes 
the  only  permanent  and  radical  means  of  relief.  It  is  founded  on 
the  general  principle,  so  often  insisted  upon  in  these  pages,  that 
irritability  is  inversely  as  the  strength,  the  vital  plower,  the  vis 
vitse.  To  give  strength,  to  impart  vital  vigor,  is  the  surest  means 
of  rendering  the  patient  less  excitable  and  less  irritable. 

The  importance  of  this  principle,  and  the  necessity  of  fulfilling 
it,  should  never  be  forgotten.  The  practitioner  should  not  be 
deceived  by  the  occurrence  of  pain,  even  intense  pain,  in  the 
head,  or  spine,  in  the  regions  of  the  heart,  lungs,  liver,  spleen, 
stomach,  intestines,  or  in  the  extremities ;  neither  by  the  sensa- 
tions of  heat  and  burning,  nor  by  the  beating,  pulsating,  distress- 
ing feelings  of  his  patient.  These,  per  se.  are  not  the  evidences 
of  inflammation,  or  even  of  congestion,  but  of  morbid  sensitive- 
ness. Evacuating  remedies,  although  occasionally  useful  for 
immediate  relief,  are  decidedly  injurious,  inasmuch  as  they  de- 
bilitate. Even  when  positive  local  inflammation  exists,  demand- 
ing some  local  antiphlogistic  treatment ;  yet,  in  the  cases  now 
contemplated,  the  general  health  and  strength  must  at  the  same 
time  be  maintained,  and  augmented  by  decided  invigorating  mea- 
sures. The  "t7i5  medicatrix  naturse'''  must  be  sustained  in  all  its 
integrity,  even  for  the  benefit  of  the  suffering  organ.  Neither  is 
this  principle  to  be  lost  sight  of  in  those  unfortunate  cases  where 
this  nervous  irritability  is  complicated  with  positive  febrile  ex- 
citement. The  mildest  anti-febrile  measures  should  be  adopted, 
and  every  opportunity  be  embraced  during  the  apyrexia,  by 
tonics,  nutritious  diet,  etc.,  to  prevent  any  further  loss  of  vital 
power. 

Nervousness  is  aggravated  by  debility ;  and  it  is  diminished  as 
vital  power  is  augmented.  This,  however,  is  not  a  mere  question' 
whether  there  be  more  or  less  blood,  whether  even  the  blood  be 
more  or  less  rich  in  red  corpuscles  or  fibrin ;  indeed,  not  a  ques- 
tion as  to  the  simple  presence  or  absence  of  "anaemia,"  as  has 
been  contended :  for,  many  ana3mic  patients  are  strong  and  not 


HYGIENIC    MEASURES.  263 

nervous,  and  many  patients  of  a  sanguine  temperament  are 
nervous.  If  tliere  be  debility,  there  is  usually  anaemia;  but 
anjBmia  may  be  relieved,  yet  nervousness  will  often  continue. 
There  are  numerous  aniemic  persons  who  enjoy  excellent  health 
and  strength.  Although  nervousness  and  anaemia  are  very  fre- 
quently coexistent,  yet  the  latter  must  not  be  regarded  as  the 
cause  of  the  former,  but  both  as  resulting  from  a  common  cause, 
namely,  the  diminution  of  vital  energy,  organic  or  animal. 

To  impart  strength  in  these  cases  should  be  the  main  object 
and  effort  of  the  practitioner. 

The  mode  or  manner,  as  well  as  the  means,  of  fulfilling  this 
indication,  are  familiar  to  every  well-instructed  practitioner. 
Here,  therefore,  the  subject  might  perhaps  be  dismissed;  but,  it 
will  no  doubt  be  useful  to  give  some  details,  as  diversities  of 
opinion  exist  on  various  points,  and  much  judgment  is  required 
in  the  management  of  the  various  complications,  arising  from  the 
peculiar  temperaments,  moral  and  physical,  and  the  constitutions 
of  the  patients.  Perhaps,  also,  some  hints  may  be  advantageously 
given  to  those  who  are,  as  yet,  inexperienced  in  the  practice  of 
the  profession. 


HYGIENIC  MEASURES. 

Food. — No  permanent  strength  can  be  imparted  without  proper 
food.  It  affords  the  material  for  the  blood,  for  nutrition,  and  for 
the  generation  of  vital  power. 

In  the  case  of  exhausted  patients,  ansemic  and  nervous,  it 
should  be  the  most  nutritious  that  can  be  procured.  Hence,  a 
preference  is  usually  to  be  given  to  the  farinaceous  substances, 
milk,  eggs,  and  meats.  The  articles  should  not  only  be  nutritive, 
but  easy  of  digestion  to  the  patient.  Any  food,  undigested,  is 
not  merely  useless,  but  positively  injurious.  For,  the  irritations 
arising  from  gas,  acrid  matters,  and  other  crudities,  disturb  the 
digestive  apparatus,  and,  it  may  be,  the  whole  economy. 

The  food,  therefore,  should  be  good  of  its  kind,  and  it  should 
be  suitably  prepared  ;  the  science  and  art  of  the  culinary  depart- 
ment should  be  attended  to.  The  diet  should  always  be  simple, 
and  especially  free  from  oily  admixtures  :  butter  or  fat,  subjected 
to  heat,  is  acrid,  irritating,  and  indigestible. 


26-i  TREATMENT    OF    IRRITABLE    UTERUS. 

It  should  be  taken  with  an  appetite ;  otherwise,  it  will  seldom 
be  well  digested.     It  is  a  very  common,  but  a  great  and  often  a 
serious  error,  to  entice  sick  persons  to  eat.     The  natural  instincts 
observed  in  the  brute  as  well  as  in  man,  should  be  regarded 
The  peculiar  tastes,  the  "  longings,"  of  patients,  even  for  articles 
of  diet  not  usually  esteemed  suitable  or  digestible,  may  some 
times,  Avithin  certain  restrictions,  be  indulged.     One  of  our  pa 
tients  could  retain  nothing  on  her  stomach  but  apples ;  another 
nothing  but   "  green  corn"  (Indian).     They  were  indulged  with 
impunity,  and  even  with  advantage.     When  there  is  little  or  no 
appetite,  nutritious  matters  may  be  administered  in  a  fluid  form, 
as  drink,  or  be  given  in  minute  quantities,  at  regular  intervals. 

In  all  cases,  the  meals  should  be  at  stated  periods,  with  inter- 
vals of  three  or  four  hours  during  the  day,  so  that  during  the 
waking  and  working  portion  of  the  day,  the  stimulus  of  food 
should  not  be  long  suspended.  The  last  meal — "the  supper" — 
should  be  light,  and  in  the  early  part  of  the  evening,  as  digestion 
is  feeble  during  the  night,  the  natural  period  of  rest  to  the  organic 
as  well  as  the  animal  functions.  The  quantity  of  food  taken  at 
any  meal  should  be  moderate,  so  that  the  powers  of  the  stomach 
should  never  be  over-taxed.  A  little  food,  well  digested,  is  useful  ; 
much  food  often  is  injurious,  as  it  over-stimulates  the  stomach,  and 
remains  undigested.  Fruits  and  vegetables,  generally,  in  all  their 
various  modes  of  preparation,  whether  fresh,  dried,  "  preserved," 
cooked  or' uncooked,  are  to  be  avoided  by  dyspeptics  as  acescent 
and  flatulent.  To  assist  the  digestive  process,  stimuli  are  often 
useful.  The  best  are  the  "  condiments,"  so  called,  especially  the 
vegetable  spices.  Occasionally,  the  malt  liquors,  wine  or  brandy, 
may  be  allowed,  yet  always  with  many  restrictions. 

Laxatives  are  often  required  to  obviate  the  usual  tendency 
to  constipation,  and  thus  to  favor  the  secretory  and  digestive 
processes.  Sometimes  simple  enemata  are  sufficient ;  in  other 
cases  we  must  employ  laxatives  of  a  tonic  character — "tonic 
laxatives" — in  small  doses,  and  at  regular  stated  intervals,  so  as 
not  to  purge,  but  to  act  merely  as  "  peristaltic  persuaders,"  and- 
produce  one  or  two  feculent  evacuations  every  day. 

Tonics  are  universally  resorted  to,  with  the  combined  object 
of  giving  an  appetite  and  imparting  strength.     Perhaps  they  have 


TONICS.  265 

been  too  mucli  relied  upon,  or,  at  least,  too  exclusively.  They 
are,  however,  very  valuable  adjuvants,  acting,  it  may  be,  slowly, 
but  efficiently ;  not  always  directly  by  imparting  strength,  but 
indirectly,  by  exciting  an  appetite,  promoting  the  secretions  from 
the  stomach,  liver,  etc.;  and  more  especially,  by  giving  energy 
to  the  vital  actions  of  the  digestive  apparatus.  Thus,  tonics  in- 
directly give  strength,  by  facilitating  the  conversion  of  nutritive 
materials  into  rich  blood,  which,  in  its  turn,  not  only  replenishes 
the  losses  of  the  economy,  but  also  imparts  activity  and  vigor  to 
all  its  functions. 

The  list  of  tonics  is  very  long,  and  a  choice  must  be  left  to  the 
judgment,  experience,  and  perhaps  it  may  be  added,  to  the  theo- 
retical views,  of  the  practitioner.  Certainly,  a  selection  should 
always  be  made,  adapted  as  far  as  possible  to  the  circumstances 
of  the  case ;  it  is  usual  to  begin  with  the  mildest  vegetable  bit- 
ters, and  afterwards  to  prescribe  those  which  are  more  stimulat- 
ing or  more  enduring  in  their  effects. 

In  nervous,  anaemic,  and  chlorotic  cases,  iron  is  universally  re- 
garded as  the  most  useful,  whether  given  in  its  pure  metallic 
state,  oxydized,  or  in  union  with  the  various  acids.  It  has  been 
exhibited  in  almost  an  endless  variety  of  combinations  with  laxa- 
tives, bitters,  alteratives,  etc.,  and  generally  with  good  results. 
Nevertheless,  it  is,  after  all,  merely  an  adjuvant,  assisting  the 
processes  of  assimilation  and  nutrition.  Certainly  the  chemical 
theory,  that  as  the  color  of  the  red  corpuscles  of  the  blood  was 
supposed  to  be  dependent  on  the  presence  of  iron,  therefore  the 
exhibition  of  this  metal  was  absolutely  necessary  in  anaemia,  has 
been  carried  to  an  extravagant,  not  to  say  a  ridiculous  extreme. 
As  if  the  Indian  warrior  from  his  venison,  the  Esquimaux  from 
his  walrus,  and  the  son  of  Erin  from  his  potatoes  and  buttermilk, 
could  not,  and  did  not,  generate  a  richer  blood,  than  the  luxu- 
rious child  of  indolence  and  fashion,  who  for  months,  or  even 
years,  has  regularly  swallowed  a  "  per  diem"  allowance  of  ferrum 
per  hydrogen,  or  the  compound  syrup  of  the  phosphates — • 
"chemical  food,"  as  it  has  been  so  quaintly  named.  As  "food," 
who  would  trust  it?  As  a  tonic,  it  is  doubtless  useful.  But, 
perhaps,  the  simple  combination  of  the  protocarbonate  of  iron 
with  the  extract  of  gentian,  or  of  cinchona,  will  prove  as  effi- 
cient as  the  apparently  more  scientific  and  complicated  prepara- 
tions. 


266  TREATMENT    OF    IRRITABLE    UTERUS. 

Fresh  and  Pure  Air  is  almost  an  absolute  requisite  for  the 
sustentation  of  animal  life,  and  even  more  necessary  for  its  resto- 
ration to  activity  and  vigor.  All  are  familiar  with  the  horrible 
depressing  influences  which  result  from  the  small  houses,  in  nar- 
row, ill-ventilated  streets ;  from  confined  apartments,  and  from  the 
dry  and  hot  atmosphere  of  modern  houses,  heated  by  stoves,  by 
grates,  by  hot  water,  or  hot  air.  In  all  of  which,  even  under  the 
best  system  yet  produced  for  ventilation,  the  "  life  of  the  air,"  its 
refreshing,  tonic,  and  stimulating  properties  are  destroyed ;  and 
hence,  the  secretions  of  the  skin,  throat,  and  lungs,  are  rapidly  re- 
moved to  the  great  detriment  of  the  economy.  No  wonder,  then, 
that  anaemia  and  other  evidences  of  exhaustion,  with  scrofulous 
and  tuberculous  developments,  are  so  common  among  the  young; 
and  cerebral  and  pulmonary  congestions  are  so  frequent  and  so 
fatal  among  adults!  Who  has  not  experienced  the  tonic,  stimu- 
lating influences  of  a  pure,  and  frosty  atmosphere  during  the 
winter;  or  the  refreshing  efiects  from  the  breezes  which  course 
among  the  tops  of  the  mountains,  or  come  sweeping  from  the 
bosom  of  the  ocean,  during  the  summer  months  ?  All  feel  and 
acknowledge  the  good,  although  the  philosopher  may  be  puzzled 
to  explain  the  cause  of  the  difference,  whether  as  depending  on 
oxygen,  electricity,  or  other  peculiar  agents. 

Under  the  head  of  defective  ventilation,  we  include  all  want  of 
purity  of  air,  whether  due  to  the  destruction  of  its  oxygenous  ele- 
ment, the  superabundance  of  carbon  and  nitrogen,  or  various  ad- 
mixtures of  more  or  less  deleterious  agents.  They  all  combine 
to  injure  directly  or  indirectly  the  vital  functions  and  activity  of 
the  economy. 

Water. — Pure  water  as  a  leverage  is  all  important.  All  addi- 
tions may  be  considered  as  injurious,  unless  specially  directed  for 
existing  circumstances. 

Water,  of  a  suitable  temperature,  should  be  freely  used  exter- 
naUy  by  all  human  beings.  It  is  requisite  for  the  purposes  of 
cleanliness,  and  for  maintaining  the  proper  softness  and  pliability 
of  the  skin,  with  its  natural  secretions  and  exhalations;  all  of 
which  are  important  for  the  health  of  the  individual. 

Much  difi'erence  of  opinion  exists  as  to  the  proper  temperature 
of  the  water  to  be  employed.  Indeed,  such  difference  is  unavoida- 
ble, because  the  experience  of  patients  and  physicians  must  vary. 


WATER.  267 

according  to  the  peculiar  temperaments  and  constitutions  of  indi- 
viduals, the  character  of  their  complaints,  the  habits  of  living,  the 
influence  of  climate,  the  season  of  the  year,  and  the  activity  and 
strength  of  the  vital  functions.  Opinion  also  varies  much  as  to  the 
questions  whether  the  application  should  be  general  or  local,  and, 
respecting  the  mode  of  administration.  Volumes  might  be  writ- 
ten on  the  use  of  water,  tepid,  warm,  and  cold.  A  few  practical 
hints,  trite  as  they  are  true,  may,  however,  be  given  as  the  result 
of  the  author's  experience  in  nervous  and  asthenic  patients. 

Warm  Water  Baths. — Although  in  a  few  individuals  of  peculiar 
temperament,  a  general  warm  bath  is  invigorating,  if  not  continued 
too  long;  it  should  usually  be  regarded  as  a  temporary  resort, 
as  relaxing  and  refreshing ;  but  it  does  not  give  strength,  and 
rather  tends  to  debilitate.  After  great  fatigue  and  exhaustion 
from  muscular  effort,  it  Avill,  however,  prove  very  refreshing. 
In  chronic  complaints  it  is  often  beneficial  in  removing  the  dry- 
ness and  roughness  of  the  epithelium,  and  facilitating  excretions 
from  the  surface. 

Local  warm  baths,  such  as  2^^diluvia  and  hip-haths,  are  invalu- 
able as  temporary  remedies  to  equalize  the  circulation,  to  soothe 
irritations,  and  to  moderate  soreness,  pains,  and  spasms.  In  the 
form  of  fomentations  and  poultices,  properly  secured  so  as  to  exclude 
the  admission  of  air,  they  are  a  continuous  warm  bath  of  the 
greatest  value,  soothing  neuralgic  irritations,  and  promoting  se- 
cretions, and,  in  every  way,  superior  to  the  painful  rubefacients 
and  blisters,  which  have  been  so  much  employed.  The  same  bland 
influences  are  experienced  in  the  use  of  warm  fluids,  as  water  or 
mucilages,  injected  into  the  rectum  and  vagina.  All  of  these  often 
form  admirable  substitutes  for  anodynes,  with  all  their  deleterious 
effects  on  the  nervous  system. 

These  local  baths  will  often  prove,  when  properly  employed, 
eflBicient  in  acute  inflammations  and  congestions;  so  that  the  irri- 
tation and  exhaustion  from  leeches  and  cups  may  be  avoided. 
Perhaps  there  are  few  greater  improvements  in  modern  practice, 
than  the  substitution  of  heat  and  moisture  for  more  direct  evacu- 
ants  and  painful  counter-irritants,  in  the  cases  of  nervous,  sensi- 
tive, and  irritable  patients. 

Nevertheless,  warm  baths  are  usually  to  be  regarded  as  tempo- 
rary remedies;  th.ey  are  relaxing  and  debilitating;  they  increase 


268  TREATMENT    OF    IRRITABLE    UTERUS. 

nervous  excitability,  although  they  diminish,  for  the  time,  nerv- 
ous excitements. 

Cold  Water  Baths. — After  acute  and  urgent  symptoms  have 
been  palliated,  then  tepid,  cool,  or  cold  water,  according  to  the 
temperament  of  the  individual,  should  be  employed.  Cold  really 
invigorates  ;  it  lessens,  and  even  destroys  morbid  excitability.  It 
diminishes  organic  actions,  or  excitements  for  the  moment ;  but, 
when  reaction  ensues,  there  is  almost  invariably  an  increase  of 
strength,  of  the  "  vis  vitse^^^  and  hence  a  diminution  of  suscepti- 
bility. How?  or  why?  are  interesting  questions;  but  the  fact 
is  incontrovertible  and  generally  recognized.  Hence  cold  air  or 
cold  water  is  tonic,  not  directly,  but  indirectly.  Hence,  also,  it 
is  tonic  and  refreshing  only  in  those  cases  where  a  glow,  a  heat, 
a  reaction  ensues.  When  there  is  no  reaction,  from  peculiar 
temperament,  or  from  great  depression  and  exhaustion,  the  direct 
sedative  influences  continue,  and  the  patient  becomes  weakened  ; 
congestions,  disease,  and  even  death  may  result.  Cold,  therefore, 
is  a  powerful  agent  for  good,  or  for  evil,  and  should  be  used  care- 
fully and  scientifically.  The  empirical  use  of  cold  water  by 
patients  or  physicians,  is  to  be  reprehended,  especially  as  em- 
ployed under  the  popular  system,  singularly  named  "hydro- 
pathy;" which,  often  very  useful,  is  frequently  injurious  and 
destructive,  as,  indeed,  its  name  imports. 

In  many  patients,  even  when  apparently  very  feeble  as  regards 
their  nervous  and  muscular  system,  and  perfectly  ansemic,  the 
general  cold  bath,  the  sJiower  or  the  plunge  bath,  is  powerfully 
refreshing  and  invigoratiDg,  a  delightful  glow  succeeding  the 
temporary  depression.  Sometimes  it  may  be  repeated  twice,  or 
even  oftener  in  the  twenty-four  hours ;  in  a  few  cases  it  may, 
perhaps,  be  prolonged  from  a  few  minutes,  which  usually  is  the 
proper  time,  to  an  hour  or  longer.  A  young  lady  that  we  knew, 
would  frequently  remain  in  a  cold  bath  for  an  hour  and  a  half, 
with  apparent  impunity. 

The  shower  bath  or  the  "douche,"  will  frequently  answer, 
where  no  reaction  will  ensue  after  immersion.  There  are  few 
patients  who  will  not  be  benefited  by  letting  water  fall  on  the 
spine  from  a  "  spout"  or  a  pitcher  ;  the  higher  the  fall  of  water, 
and  the  more  prolonged  the  time  employed,  the  greater  the  im- 
pression. This  operation  should  be  immediately  succeeded  by 
frictions  with   coarse  towels,  flannels,   hair  gloves,   etc.,  and  if 


COLD    WATER    BATHS.  269 

needs  be,  by  stimulating  liniments  and  rubefacients.  In  some 
cases,  especially  in  winter,  the  patient's  back  being  ^exposed  to 
the  direct  heat  of  a  fire,  and  the  rest  of  the  person  protected  by 
blankets,  the  "douche"  may  be  resorted  to  with  great  freedom, 
and  almost  a  certainty  of  a  favorable  reaction.  Cold,  when  thus 
used  merely  to  the  spine,  is  invaluable;  but  it  can  almost  always 
be  usefully  employed  to  the  rest  of  the  body  and  the  extremities, 
also  by  means  of  cloths  and  sponges,  followed  by  frictions. 
Perhaps  no  woman  in  non-menstruating  condition,  should  neglect 
the  free  use  of  cold  water  to  the  pudendum,  at  least  once  every 
day. 

Cold  water  injections  to  the  vagina  should  be  a  daily  resource, 
except,  of  course,  at  the  catamenial  periods,  in  all  cases  of  chronic 
irritable  uterus,  either  with  or  without  leucorrhoeal  discharges ; 
provided  pain  be  not  produced.  If  it  does  occasion  pain,  then 
cool  or  tepid  water  should  be  substituted.  Tepid  or  cold  water 
to  the  rectum,  also,  is  occasionally  very  advantageous.  In  all 
cases  of  vaginal  and  rectal  injections  there  should  be  a  pleasant 
reaction;  if  there  be  too  much  pain  or  heat  excited,  let  cool  or 
tepid  water  be  employed  for  a  time,  until  the  lower  temperature 
can  be  borne. 

It  is,  perhaps,  unnecessary  to  dwell  on  the  inestimable  value 
of  this  agent  in  nervous  affections,  through  its  combined  sedative 
and  invigorating  influences.  It  imparts  strength  and  diminishes 
irritability.  The  use  of  water,  locally  and  generally,  and  at  suit- 
able and  varying  temperatures,  ought  to  supersede,  as  already 
intimated,  the  use  of  many  of  the  positive  direct  evacuants,  the 
deleterious  anodyne  drugs,  and  the  painful,  irritating,  rubefacient 
revulsive  agents.  These  last,  in  nervous  patients,  constantly  act, 
not  as  "counter-irritants,"  but  as  direct  local  and  general  ex- 
citants to  the  whole  nervous  and  even  vascular  system;  'so  that 
instead  of  removing  they  often  terribly  aggravate  every  morbid 
sensation,  Eemedial  agents  in  irritable  patients  should  never 
excite  pain  of  a  continuous  character. 

A  very  important  mode  of  securing  reaction  after  the  use  of 
cold  water,  is  by  means  of  "the  packing  system^'^  as  it  has  been 
familiarly  called.  The  whole  body  and  extremities  are  covered 
with  a  sheet  dipped  in  water  of  a  temperature  adapted  to  the 
particular  case,  and  the  patient  is  then  enveloped  by  a  series  of 
blankets  and  "  comforts."     In  a  very  short  time,  reaction  ensues, 


270  TREATMENT    OF    IRRITABLE    UTERUS. 

the  cold  sheet  becomes  warm,  perspiration  follows,  and  is  kept 
up  for  a  longer  or  shorter  period,  at  the  discretion  of  the  ope- 
rator ;  so  that  the  patient  has  really  all  the  advantages  of  a  hot 
vapor  bath.  In  some  cases  the  reaction  is  so  great,  that  even 
papular  or  erythematic  eruptions  ensue.  The  "local  packing"  to 
the  neck,  chest,  abdomen,  etc.,  is  still  more  agreeable,  and  gene- 
rally more  advantageous.  In  pelvic  distress,  especially,  it  is 
usually  very  beneficial. 

Exercise  and  Eest. — Exercise  has  always  been  regarded  as 
very  important  for  all  excitable  nervous  women.  Popularly,  the 
most  extreme  notions  have  been  urged  on  this  subject,  very  often 
to  a  most  uncharitable  extent.  "  She  is  rich,  therefore  she  is 
nervous;  if  she  had  to  work  for  her  living  she  would  soon  be 
well."  "It  is  indolence,"  "  self-indulgence."  "  It  is  notional ;  she 
cau  go  out  if  she  pleases."  "  Let  her  work,  then  she  will  sleep ; 
and  Ave  shall  hear  no  more  of  pains  and  aches,  of  her  affectation, 
and  her  hysterical  notions."  Physicians  often  run  into  the  same 
extreme.  A  clergyman,  whose  mind  and  heart  had  been  over- 
taxed, presented  himself  to  us  a  few  days  since  to  obtain  a  rule 
respecting  his  future  course,  as  one  physician  advised  him  to  labor 
all  day  at  hard  work,  that  he  might  sleep  well  and  be  strength- 
ened. Another  advised  perfect  rest,  day  as  well  as  night,  for 
mind  and  body,  that  he  might  recover  his  lost  energies. 

Power  accumulates  on  resting.  Hence,  the  Indian  warrior, 
the  sportsman,  the  laborious  farmer,  and  the  industrious  artisan, 
refresh  their  exhausted  energies  by  rest.  It  is  imperiously  de- 
manded, and,  if  denied,  prostration,  or  even  death,  must  result. 
When  the  body  is  at  rest,  there  may  be  undue  mental  and  moral 
excitement,  exhausting  power;  and  hence,  the  student,  the  philo- 
sopher, and  those  whose  hearts  are  oppressed  by  care  and  anxiety, 
also  demand  rest,  if  rest  can  be  found,  for  the  recovery  of  mental 
and  moral  power. 

Continued  rest,  however,  is  as  injurious  almost  as  excessive 
labor.  Without  sufficient  excitement,  the  nervous  system  be- 
comes weakened,  muscular  energy  is  diminished,  the  whole  sys- 
tem becomes  morbidly  sensitive  and  irritable,  little  things  produce 
powerful  impressions;  the  patient,  indeed,  is  nervous,  hysterical. 
The  mind  suffers  with  the  body;  both  the  organic  and  animal 
actions,  generally,  become  weakened;  dyspepsia,  anosmia,  palpi- 


EXERCISE    AND    REST.  271 

tations  of  the  heart,  emaciation,  wasting  of  the  muscular  tissues, 
loss  of  sleep,  spasms,  and,  sometimes,  convulsions,  are  among  the 
consequences.  Many  of  these  symptoms  are  dependent  on,  or 
complicated  with,  more  or  less  congestion  of  the  internal  organs, 
as  manifested  by  the  coldness  and  pallor  of  the  surface,  especially 
of  the  extremities,  and  by  the  increased  sensations  of  fulness, 
stricture,  and  oppression  about  the  head,  chest,  and  abdomen. 
The  blood  circulates  slowly,  and  may  become  semi-stagnant,  par- 
ticularly in  the  large  trunks  of  the  venous  system.  Sometimes 
even  secondary  complaints,  chronic  inflammations,  tuberculous 
and  scrofulous  affections,  follow  in  this  train  of  morbid  develop- 
ments. 

Labor  and  rest,  rest  and  labor,  is  the  law  of  animal  nature.  All 
know  this;  its  exemplification  is  seen  in  all  the  gambols  and 
frolics  of  the  young,  as  well  as  in  the  active  employments  of 
healthy  and  vigorous  adults. 

Exercise  stimulates  the  nervous  and  the  circulatory  systems, 
the  animal  and  the  organic  life.  The  brain  and  spinal  marrow, 
the  nerves  of  sensation  and  those  of  motion,  with  their  muscular 
appendages,  all  gain  power  when  excited,  if  not  for  too  long  a 
time,  or  too  intensely.  The  various  secretions  and  excretions, 
the  functions  of  the  stomach,  intestines,  liver,  and  kidneys,  the 
actions  of  the  heart  and  lungs,  are  all  excited;  there  is  better 
digestion,  better  chylification,  better  haematosis,  better  respiration, 
better  nutrition,  and  of  course  better  development  of  all  the  tis- 
sues and  organs.  The  circulation  is  not  merely  stimulated,  but 
it  is  equalized.  The  semi-stagnation  of  the  blood,  the  congestions 
of  the  internal  organs,  is  relieved;  the  blood  is  "pumped"  from 
the  interior  to  the  exterior,  and  from  the' large  venous  trunks  to 
the  capillary  tissues  of  the  interior  as  well  as  to  the  exterior  sur- 
faces. There  is  an  actual  increase  of  power,  resulting  from  this 
excitation,  if  it  be  not  carried  too  far;  and  hence,  as  a  necessary 
result,  a  diminution  of  nervous  excitability.  The  irritability  of 
the  brain  and  its  dependencies,  and  of  course,  also,  the  mental  and 
moral  susceptibilities,  are  lessened. 

To  obtain  these  good  results  the  rest  should  be  proportioned  to  the 
labor.  He  who  works  hard,  should  have  a  great  deal  of  rest  and 
sleep.  This  last  may  be  regarded  as  perfect  rest,  a  temporary 
insensibility  to  all  stimuli,  and  to  all  animal  excitations.  The 
violation  of  this  rule  is  very  frequent,  and  very  injurious,  espe- 


272  TREATMENT  'OF    IRRITABLE    UTERUS. 

cially  in  tlie  treatment  of  the  hysterical,  delicate,  and  anasmic 
woman.  Her  power  is  feeble ;  a  slight  exertion  exhausts.  The 
elevation  of  the  head  from  the  pillow  will  cause  sensations  of 
weakness,  even  faintness  in  some ;  others  can  tolerate  the  sitting 
but  not  the  standing  position;  some  will  bear  exercise  by  gestation 
but  cannot  make  any  muscular  effort  with  impunity.  The  degree 
of  exercise,  of  muscular  effort,  must  always  be  proportioned  to 
the  degree  of  strength  actually  existing.  What  is  a  moderate 
effort  for  one,  is  perfectly  exhausting  for  another.  These  are 
truisms  ;  but,  nevertheless,  they  are  often  neglected.  Much  must 
be  left  to  the  discretion  of  the  patient ;  nevertheless  the  active, 
the  restless,  the  impatient,  the  impulsive,  and  the  woman  of  strong 
will,  must  often  be  restrained.  They  make  too  great  or  too  pro- 
longed an  effort,  or  they  refuse  to  take  sufiicient  rest.  On  the 
contrary,  the  listless,  the  timid,  the  sensitive,  the  inert,  and  im- 
passive girl,  must  be  persuaded,  urged,  sometimes  almost  forced, 
to  make  an  effort. 

Temptations  to  exertion,  of  every  kind,  may  be  frequently  pre- 
sented ;  and  when  the  mind  of  the  patient  is  interested  and  em- 
ployed, it  is  wonderful  what  the  body  will  often  accomplish. 
Many  of  our  patients,  long  confined  to  their  couch  at  home,  have 
been  carried  hundreds  of  miles  by  rail  and  steamboat  to  Phila- 
delphia, and  found  themselves  even  better  for  the  journey. 

To  those  who  cannot  be  moved,  frictions  to  the  whole  surface 
are  advantageous,  although  imperfect  substitutes  for  motion.  By 
them,  blood  is  determined  to  the  exterior  to  the  relief  of  internal 
congestions.  But  exercise,  even  for  both  the  upper  and  lower 
extremities,  may  be  obtained,  while  the  patient  remains  in  bed,  by 
means  of  elastic  cords  so  arranged  that  they  may  be  stretched  at 
will  by  means  of  the  hands  and  feet. 

The  patient  should  often  have  her  position  changed  in  the  bed, 
or  from  one  bed  to  another,  or  to  a  lounge,  or  hammock.  When 
she  can  bear  it,  she  should  sit  up,  which  is  an  exercise  to  those 
not  accustomed  to  it.  Patients  should  be  made  to  stand  by  the 
support  of  the  nurse,  a  chair,  or  crutches,  before  they  can  even 
sustain  their  whole  weight  by  themselves. 

Walking  may  often  be  attempted  thus  supported,  even  before- 
the  patient  can  elevate  her  feet  from  the  floor.     In  one  case,  we 
have  had  a  young  lady  to  move  up  and  down  the  room  by  means 
of  a  chair,  at  a  time  when  spasms  of  all  her  muscles  would  ensue, 


EXERCISE    AND    REST.  273 

if  a  foot  was  raised  even  a  quarter  of  an  inch  from  the  floor.  All 
these  attempts  are  to  be  encouraged.  Too  much  cannot  be  said 
in  favor  of  walking  as  a  mode  of  exercise;  indeed,  it  is  to  be  pre- 
ferred for  invalids,  to  all  those  innumerable  modes  of  muscular 
eftbrts  manifested  bj  the  sports  of  children,  the  games  and  recrea- 
tions of  the  young,  and  the  harder  work  of  the  adult.  It  is  na- 
ture's mode. 

Exercise  hy  gestation,  whether  in  the  nurse's  arms,  in  the  garden 
chair,  the  carriage,  the  swing,  the  railroad  car,  the  steamboat,  or 
the  ship,  are  all  valuable;  but  they  are  imperfect  substitutes  for 
decided  action  of  the  whole  muscular  system.  Exercise  on  horse- 
lack  is  advantageous  as  agitating  the  viscera,  stimulating  the  cir- 
culation, and  giving  a  certain  degree  of  action  to  the  muscles. 
Sailing  is  also  most  admirable  for  the  valetudinarian.  The  agita- 
tions of  the  vessel,  from  the  deep  swelling  of  the  mighty  ocean, 
allow  of  no  rest  to  the  muscles,  per  noctem  or  per  diem.  The 
action  may  be  insensible,  but  it  is  positive,  continuous,  and  pro- 
portionally beneficent. 

The  best  rule  for  patients,  as  respects  all  these  modes  of  exer- 
cise, is,  that  short  and  frequent  efforts  should  be  made,  always 
stopping  if  great  fatigue  or  much  pain  be  experienced.  As  regards 
pain,  there  are,  however,  some  exceptions  to  this  rule,  arising 
from  its  diverse  character  and  causes.  There  are  many  muscular 
pains,  such  as  soreness  and  stiffness,  which  are  dissipated  by  ex- 
ercise. For  example,  much  soreness  is  often  induced  by  exercise 
on  horseback.  It  is  the  result  of  the  unaccustomed  effort,  and  is 
graduall}^  dissipated  by  repetition  ;  the  oftener  they  walk  or  ride, 
the  less  the  uneasiness.  But  this  principle,  too,  has  been  inju- 
diciously applied,  so  that  the  attempt  has  been  made  to  destroy 
neuralgic  pains  by  exercise.  Poor,  delicate,  suffering,  agonized 
patients  have  been  forced  to  move,  to  the  increase  of  their  suffer- 
ings and  the  aggravation  of  their  complaints.  The  best  rule  to 
adopt  is,  to  be  governed  by  the  sensations  of  the  patient.  Insist 
on  as  much  exercise  by  walking  or  driving  as  does  not  perma- 
nently increase  the  sufiering.  When  pain  is  aggravated,  desist, 
and  ascertain  the  cause. 

Much  difference  of  opinion  has  existed  as  to  the  time  for  exer- 
cise. The  general  principle,  derived  from  experience  and  the 
observation  of  the  natural  diurnal  revolutions  of  the  econonw, 
is,  that  the  morning  is  the  period  for  hard  labor  and  substantial 
18 


274  TREATMENT  'OF    IRRITABLE    UTERUS. 

diet,  the  evening  for  recreation  and  refreshments,  and  the  night 
for  perfect  c^uietude  and  sleep.  Although  this  law  is  frequently 
and  indeed  constantly  violated  in  civilized  communities,  it  is 
nevertheless  the  natural  law,  and  should  govern  the  medical 
philosopher  in  his  directions.  These,  however,  will  often  be  in 
opposition  to  the  sensations  and  wishes  of  his  nervous  patients. 
They  would  reverse  the  rule.  They  "  feel"  miserable  and  wretched 
in  the  mornings,  and  are  bright  and  excited  in  the  evenings.  They 
T-ilead  for  late  rising,  and  for  late  retiring. 

But  certainly  the  languor  and  inertness  of  the  morning  cannot 
arise  from  the  want  of  rest,  when  this  has  already  been  enjoyed 
for  some  eight  or  twelve  hours  consecutively.  Their  miserable 
sensations  of  exhaustion  are  owing  rather  to  the  want  of  excite- 
ment;  to  the  confinement  in  the  close  air  of  a  chamber,  injured 
by  the  excretions  from  the  lungs,  skin,  etc.,  by  the  burning  of  the 
lamp  or  gas,  and,  in  winter,  by  the  heat  of  stoves,  furnaces,  etc. 

The  excitements  of  the  evening,  however  pleasant  and  exhila- 
rating, are  nevertheless  often  deleterious  to  the  nervous  patient. 
These  excitements  are  frequently  inordinate,  and  disproportioned 
to  her  real  strength.  Hence  they  are  followed  by  a  correspond- 
ing collapse,  greatly  aggravating  the  usual  morning  sensations  of 
languor  and  debility;  they  are  analogous  to  those  of  the  inebriate 
and  the  epicure  after  their  nocturnal  banquets. 

Conclusions. — Let  the  natural  law,  therefore,  be  brought  to 
bear  fully  on  the  conduct  of  the  patients.  Let  them  rise  early, 
be  carried  at  once  to  a  fresh  room,  then  the  cold,  sponge,  or  plunge- 
bath,  to  be  followed  by  dry  and  rough  frictions,  and  rapid  dress- 
ing with  sufficient  clothing.  Let  them  have  a  warm  drink,  with 
a  mouthful  of  food ;  then  a  drive  out-doors,  or  a  walk,  if  possible, 
soon  returning  home  for  a  substantial  breakfast  and  a  morning's 
siesta  or  sleep,  if  needs  be.  Before  dinner  let  them  take  another 
bath  and  a  walk.  After  dinner,  there  should  be  more,  rest  and 
quietude;  then  the  third  walk,  a  light  supper,  and  an  early  retire- 
ment to  a  well-ventilated  apartment.  This  general  rule  should  be 
proportioned,  as  above  mentioned,  to  the  powers  of  the  patient. 
But  the  principle  of  alternate  rest  and  labor  should  always  be 
maintained  as  a  fundamental  law  of  tlie  animal  economy. 


ACUTE    GASES.  275 


MEDICINAL  AGENTS. 


Thus,  by  removing  the  causes,  and  then  increasing  the  energies 
of  the.  nervous  system  by  these  hygienic  and  tonic  measures,  we 
may  expect  to  accomplish  much  in  these  irritable  complaints. 
Recoveries  are  often  surprising  and  rapid.  Much,  however,  can 
be  done  in  facilitating  this  desirable  event  by  general  and  local 
medicinal  agents.  As  some  modifications  of  treatment  are  requi- 
site in  the  management  of  the  acute  and  chronic  forms  of  the 
complaint,  thej  will  be  spoken  of  separately. 

Acute  Cases. — In  acute  cases,  where  there  is  much  suffering, 
especially  when  the  attack  has  been  sudden,  "perfect  rest  is  de- 
manded. Motion  increases  pain;  indeed,  it  is  often  impossible, 
from  the  severe  cramps,  spasms,  or  even  convulsions,  which  may 
exist.  So,  also,  in  the  neuralgic  states  of  the  uterus,  so  common 
after  parturition,  rest  is  essential,  not  merely  to  moderate  pain, 
but  to  prevent  displacement  of  the  uterus.  Immediately  after 
delivery,  and  even  for  weeks,  this  organ  is  so  large  and  heavy, 
and  its  natural  supports,  elongated  by  pregnancy,  are  so  relaxed 
and  weakened,  that  displacement  is  apt  to  occur,  and  increase  all 
the  neuralgic  tendencies. 

Loss  of  Blood. — Occasionally  in  women  of  full  habit,  where 
there  is  much  general  plethora,  or  even  in  cases  of  severe  local 
congestion  arising  from  exposure  to  cold,  the  approach  of  the 
catamenia,  or  even  from  the  intensity  of  the  nervous  irritation, 
some  loss  of  blood  may  be  very  useful.  In  a  few  such  cases,  a 
general  bleeding  is  beneficial,  but  usually  local  depletion  is  all 
sufficient.  Cups,  therefore,  to  the  sacral  region,  to  the  abdomen, 
or  leeches  to  the  hypogastric  or  iliac  regions,  to  the  insides  of  the 
thighs,  and  to  the  pudendum,  are  very  advantageous.  The  once 
common  practice,  and  still  maintained  by  many,  of  applying 
leeches  and  scarifications  to  the  uterus  itself  has  little  to  recom- 
mend it.  The  relief  is  no  greater,  while  the  mental  and  physical 
irritation  from  the  use  of  the  speculum,  the  pain  of  the  operation, 
and,  the  subsequent  irritations  from  the  leech-bites  or  the  inci- 
sions, often  counteract  entirely  the  benefits  from  the  evacuation. 

This  local  depletion  is,  however,  rarely  required,  and,  when 
necessary,  ought  seldom  to  be  repeated,  for  reasons  already  fre- 


276  TREATMENT    OF    IRRITABLE    UTERUS. 

quentlj  adduced,  even  when  congestions  exist.  The  cause  of 
the  congestion  should  be  removed  and  thus  indirect!}^  the  con- 
gestion itself,  rather  than  employ  any  direct  means  of  reducing 
the  turgescence  of  the  vessels. 

Revulsives.— 1\\  the  form  of  hot  baths,  warm,  hip-baths,  and 
particularly  of  large  warm  poultices  and  fomentations,  revulsives 
are  exceedingly  soothing  and  palliative.  So  also,  large  warm 
mucilaginous  or  watery  vaginal  injections,  and  sitting  over  the 
vapor  of  hot  water  or  hot  decoctions  of  herbs,  solace  the  sufferings 
of  the  patients. 

They  soothe  nervous  irritations,  as  formerly  mentioned,  and 
also  relieve  congestions,  not  merely  by  determining  to  the  sur- 
face, but  by  promoting  the  secretions.  They  cause  vital  relaxa- 
tion. This  influence  is  often  increased  by  the  conjoint  use  of  oil 
and  laudanum,  of  camphor,  of  anodyne  and  stimulating  liniments 
to  the  surface. 

Sinapisms  may  be  occasionally  resorted  to  for  a  short  time  with 
advantage.  But,  for  many  years,  we  have  nearly  abandoned  the 
use  of  painful  revulsives  in  nervous  patients.  They  act  as 
general  stimuli,  not  as  counter-irritants;  they  disturb  the  brain 
and  the  mind  of  the  patient.  Much  mischief  has  resulted  from 
sinapisms,  blisters,  tartar  emetic,  setons,  issues,  moxas,  and  the 
actual  cautery  to  the  spine  for  so-called  cases  of  spinal  irritation. 
Although  temporary  relief  is  occasionally  afforded,  permanent 
injur}^  is  inflicted  by  the  increase  of  irritation  and  pain,  disturb- 
ing the  whole  nervous  system. 

Narcotics. — The  chief  dependence  of  the  physician  in  acute 
attacks  of  pain  and  spasms,  must  be  in  narcotics.  They  may  be 
administered,  as  usual,  by  the  mouth ;  but  sometimes  with  great 
effect,  locally.  Hence,  the  hop-poultice,  frictions  with  oil  and  lau- 
danum, applications  of  camphor,  belladonna,  aconite,  and  chloro- 
form, are  all  more  or  less  useful.  Subcutaneous  injections  of 
morphia,  etc.,  are  very  efficient.  Vaginal  enemata  of  laudanum, 
morphia,  and  camphor,  with  some  patients  are  decidedly  influen- 
tial, partic'ularly  when  retained  for  a  length  of  time.  These  nar- 
cotics are  often  more  efficient  in  the  form  of  vaginal  suppositories. 
The  most  soothing  and  important  effects  often  result  from  rectal ' 
anodyne  enemata  or  suppositories.  The  quantity  of  the  narcotic 
should  be  in  proportion  to  the  necessities  of  the  case,  and  should 
be  repeated  as  may  be  advisable. 


CHRONIC    CASES.  277 

Chronic  Cases. — In  chronic  forms  of  irritable  uterus,  the 
treatment  must  be  greatly  modified.  When,  however,  there  are 
occasional  paroxysms  of  suffering,  as  is  frequently  the  case,  the 
rest,  fomentations,  and  anodynes  become  essential.  But,  usually, 
oar  guiding  principle  should  be,  not  so  much  the  mere  relief  of 
pain  by  direct  measures,  as  the  removal  of  the  cause  of  pain.  To 
the  scientific  mind,  it  is  not  suf&cient  to  say  that  it  is  neuralgia, 
and  to  treat  it  accordingly.  Pain  is  a  state  of  nervous  irritation, 
and  implies,  therefore,  whenever  it  occurs,  not  only  mere  sensi- 
tiveness of  the  tissue,  natural  or  morbid  irritability,  but  also  an 
irritant,  whether  seen,  or  unseen,  known,  or  unknown.  The  essen- 
tial mode  of  relieving  pain  is  to  remove  the  irritant;  take  away 
the  mote  from  the  eye,  or  the  thorn  from  the  flesh,  if  you  expect 
to  afford  radical  relief.  All  other  treatment  is  palliative.  Hence, 
as  has  been  constantly  insisted  upon,  in  the  previous  chapters,  the 
cause  of  uterine  irritation  must,  if  possible,  be  relieved.  This  can, 
very  frequently,  be  readily  accomplished.  When  displacements 
exist,  let  the  uterus  be  fully  reinstated  and  kept  in  its  natural 
position,  simply  in  contact  with  the  bladder  and  the  small  intes- 
tines, the  softest  bed  that  can  be  imagined;  then  it  will  be  no 
longer  irritated  by  pressure  against  the  perineum,  the  rectum  with 
its  feculent  contents,  or  the  sacrum,  but  it  will  fall  into  a  quiescent 
state.  If  the  uterus  be  not  particularly  sensitive,  and  if  there  be 
no  other  disease  present,  the  patient  often  at  once  declares  herself 
well,  feels  well,  and  acts  well. 

If,  however,  there  be  great  sensitiveness,  either  local  or  gene- 
ral; then  there  is  occasional  suffering  from  the  slightest  cause,  as 
from  tympanites,  from  distension  of  the  bladder,  from  a  costive 
stool,  from  diarrhoea,  indigestion,  and  mental  or  moral  agitation. 
For  this  morbid  irritability,  the  general  treatment  already  di- 
rected is  important,  and  is  to  be  assisted  by  local  means.  Time, 
however,  is  required,  and  a  combination  of  favorable  circum- 
stances, moral  as  well  as  physical,  is  necessary  to  destroy  this 
morbid  susceptibility,  and  so  to  revolutionize  the  system;  so  that 
ordinary  impressions  shall  have  no  extraordinary  influences. 

Loss  of  Blood. — Even  when  the  local  congestion  and  the  pain 
are  severe,  it  is  very  rarely  that  loss  of  blood,  even  by  cups  or 
leeches,  should  be  resorted  to  in  chronic  cases.  They  debilitate, 
and  thus  increase  the  soreness  and  nervousness. 

Warm  Water. — Warm  baths,  poultices,  and  warm  vaginal  injec- 


278  TREATMENT    OF    IRRITABLE    UTERUS. 

tions  are  always  palliative  and  grateful.  In  some  peculiar  tem- 
peraments, and  delicate  women,  they  have  to  be  persevered  in ; 
but  after  a  time,  they  usually  relax  so  much,  that  the  parts  be- 
come even  more  sensitive. 

Cold  Water. — The  best  means  of  diminishing  and  destroying 
much  irritability  is  by  means  of  cold,  or  cool  water.  This  is  true 
of  the  local  as  well  as  of  the  general  use  of  cold  water.  The  douche, 
therefore,  as  already  recommended  for  the  back,  the  loins,  and 
the  sacrum,  should  be  employed ;  but  the  sponging  also  of  the 
abdomen,  the  thighs,  and  the  pudendum,  with  cold  water  several 
times  a  day,  is  very  tonic  and  refreshing,  especially  when  followed 
by  frictions. 

Of  late,  the  cold  hip,  or  "  sitz  bath,"  has  been  strongly  recom- 
mended, and  no  doubt  is  often  very  advantageous ;  but  caution 
is  requisite  in  its  use.  Patients  often  remain  too  long  in  it  and 
become  chilly.  In  many,  there  is  an  aggravation  of  the  cold  hands 
and  feet,  so  common  to  nervous  individuals ;  sometimes  there  is 
an  increased  determination  to  the  head,  so  that  injections  of  the 
face,  eyeSj  and  brain,  result  with  more  or  less  cephalic  irritation. 
When  employing  the  hip-bath,  we  advise  the  head  to  be  covered 
with  cold  cloths,  and  the  feet  to  be  immersed  in  warm  water,  so 
as  to  prevent  unequal  determinations  or  revulsions. 

Tepid,  cool,  or  cold  vaginal  injections,  according  to  the  sensa- 
tions and  experience  of  the  patients,  are  very  valuable  for  three 
weeks  in  the  month.  Of  course  they  are  to  be  omitted  during  the 
catamenial  week.  They  quiet  irritation,  diminish  heat  and  conges- 
tion, lessen  the  morbid  sensibility,  and  give  tone  to  all  the  tissues. 
Many  object  to  their  use  lest  they  should  produce  pain,  rheu- 
matism, etc.  This,  however,  is  seldom  the  case.  Let  the  patient 
begin  with  tepid  water ;  soon,  she  will  be  able  to  use  it  quite  cool, 
even  if  not  cold,  with  impunity  and  advantage.  In  girls  of  warm, 
excitable,  erotic  temperaments,  where  the  imagination  has  been 
unduly  stimulated  by  improper  conversation,  plays,  romances,  etc., 
the  free  use  of  cold  water  thus  internally  and  externally  is  our  best 
resort. 

Cold  rectal  enemata  are,  to  many,  almost  as  useful,  on  the  same 
principles,  particularly  when  the  bowels  are  costive.  They  cannot 
always,  however,  be  employed,  as  they  not  unfrequently  excite 
pain ;  indeed,  with  many  patients,  the  least  distension  of  the  rec- 
tum causes  more  or  less  irritation. 


NARCOTIC    APPLICATIONS.  279 

Another  plan  of  applying  cold  locally,  already  alladed  to,  con 
sists  in  placing  tqwels,  wet  with  cold  water,  over  the  abdomen, 
or  around  the  hips,  and  covering  them  up  with  flannels  and 
bandages.  In  a  short  time  the  heat  of  the  body  generates  a  vapor 
bath,  and  profuse  perspiration  ensues.  Perhaps  there  may  be  a 
more  decided  effect  produced  in  robust  persons  by  this  reaction, 
after  the  shock  caused  by  the  cold,  as  evinced,  not  only  by  great 
sensations  of  heat,  but  by  the  formation  of  a  papillary  eruption. 
This  is  often  very  advantageous,  and  may  occasionally  be  em- 
ployed. In  delicate  persons,  however,  greater  benefit  may  be 
obtained  from  cloths  dipped  in  warm  water,  and  then  covered 
with  oiled  silk  or  flannels. 

Narcotic  Applications. — Another  adjuvant  is  the  direct  applica- 
tion of  narcotics  to  the  uterus.  Various  articles  have  been  re- 
sorted to,  and  in  every  variety  of  form,  whether  in  powders, 
watery  solutions,  tinctures,  ointments,  suppositories,  or  gases ; 
occasionally  they  have  been  injected  into  the  cavity  of  the  neck 
and  body  of  the  uterus. 

The  real  value  of  this  practice,  though  apparently  very  reason- 
able, has  not  yet  been  fully  developed.  Great  confidence  has  been 
placed  in  it  by  some,  and  the  results  of  anodyne  frictions  to  the 
cervix,  by  an  empirical  practitioner,  have  been,  as  reported  by 
patients,  very  wonderful.  Anodynes  to  the  vagina  and  uterus 
are  often  palliatives,  and  may  freely  be  employed,  as  the  narcotic 
influences  upon  the  general  system  are  not  very  decided,  and  per- 
haps no  detriment  is  likely  to  ensue.  We  have  used  them  freel}^ 
as  injections  and  suppositories,  but  with  no  very  decided  results. 
They  diminish  the  irritation  for  the  time,  but  have  no  abiding- 
influence. 

In  the  use  of  powders  and  ointments,  tubes  are  required,  so  as 
to  pass  them  fairly  through  the  orifice  of  the  vagina.  The  best 
material  for  a  suppository  is  the  butter  of  cocoa.  This,  when 
genuine,  is  sufficiently  firm  to  allow  a  patient  to  introduce  it,  and 
yet  melts  very  rapidly  by  the  heat  of  the  body.  Washes  may  be 
often  advantageously  employed,  by  means  of  the  speculum,  di- 
rectly to  the  neck  and  orifice  of  the  uterus,  if  needs  be;  but  all 
such  operations  with  the  speculum  are,  in  themselves,  irritating, 
and  should  be  avoided  as  much  as  possible.  In  the  form  of  gas, 
carbonic  acid  and  chloroform,  as  recommended  by  Prof.  Simpson, 
may,  by  means  of  a  tube,  be  brought  directly  in  contact  with  the 


230  TREATMENT    OF    IRRITABLE    UTERUS. 

vagina  and  uterus.  Sucli  anodjnie  powers  as  may  prove  to  be- 
long to  these  gases  are  thus  readily  obtained. 

As  occasional  remedies,  anodyne  rectal  enemata  are  very 
efficient;  but  as  these  have  a  decided  narcotic  inflaence  on  the 
brain,  they  should  be  subjected  to  the  restrictions  already  given 
as  to  the  use  of  narcotics  in  chronic  diseases. 

Apjjlkations  of  Nitrate  of  Silver. — The  nitrate  of  silver  has  long 
been  known  as  possessing  peculiar  powers  of  diminishing  the 
irritability  of  tissues,  to  which  it  is  applied.  Surgeons  had  often 
employed  it  for  irritable  sores,  irritable  excrescences,  and  even 
to  irritable  states  of  the  cornea,  with  the  happiest  effects.  Physi- 
cians had  recommended  it  in  morbid  irritability  of  the  stomach, 
and  bowels.  It  was,  therefore,  very  soon  applied  to  irritable 
uterus.  Perhaps  this  remedy  is  employed  by  every  practitioner, 
whatever  may  be  his  theoretical  opinions  as  to  its  modus  operandi. 
A  few  years  ago,  uterine  diseases  were  treated  as  spinal  irritation, 
with  the  tartar  emetic  ointments  applied  from  occiput  to  coccyx ; 
in  the  practice  of  the  present  day,  the  application  of  nitrate  of 
silver  to  the  os  uteri  is  equally  universal. 

That  good  effects  have  often  resulted  is  evident,  from  the  fact 
that  the  fashion  has  so  long  continued.  In  cases  of  decided 
inflammation  of  the  mucous  membrane  of  the  cervix  and  the  os, 
it  is  often  very  useful,  more  so,  however,  when  applied  in  solu- 
tion than  in  the  solid  state.  It  facilitates  "resolution."  But,  as 
formerly  contended,  after  the  inflammation  has  disappeared,  the 
irritable  symptoms  may,  and  often  will,  remain ;  sometimes  even 
after  the  frequent  use  of  the  nitrate  has  been  continued  for  years. 

In  pure  cases  of  irritable  uterus,  we  have  known  much  tempo- 
rary benefit  result  from  the  lunar  caustic  by  diminishing  morbid 
sensitiveness ;  but  our  experience  has  been  that  there  is  seldom 
permanent  relief. 

A  little  consideration  would,  perhaps,  have  indicated  this  by 
"  ct  priori''^  reasoning.  A  very  small  part  of  the  uterus  is  accessi- 
ble to  direct  applications.  They  influence  merely  that  portion, 
less  thau  a  fourth,  of  the  neck  which  projects  into  the  vagina. 
But  the  whole  uterus  is  morbidly  sensitive,  and  not  merely  the 
neck.  Pressure  on  the  anterior  part  of  this  organ,  through  the 
walls  of  the  bladder,  or  on  the  posterior  portion,  through  the 
rectum,  gives  exquisite  pain,  occasionally  so  intolerable  that  a 
cataleptic  or  hy.sterica]  insensibility  ensues.     On  this  account,  we 


GENERAL    REMARKS.  281 

might  have  expected  the  failure  of  the  nitrate  in  such  cases ; 
although  a  partial  and  temporary  relief  from  its  occasional  use 
may  be  obtained. 

Afechcmical  Measures. — It  is  well  known  surgically,  that  the 
sensibility  of  tissues  may  be  blunted  by  mechanical  means.  The 
tissues  may  be  "  hardened."  The  first  introduction  of  a  bougie 
into  the  urethra  causes  pain,  followed,  it  may  be,  by  a  chill  or 
faintness.  In  a  short  time  it  is  borne  with  impunity,  if  the  opera- 
tion has  been  carefully  repeated.  On  the  same  principle,  bougies 
have  been  introduced  into  the  neck  and  body  of  the  uterus  with 
varying  success.  So  much  pain  and  irritation  is  generally  ex- 
cited, even  after  repeated  trials,  that  frequently  neither  patient 
nor  practitioner  will  persevere.  In  a  few  cases,  we  have  known 
the  practice  to  be  useful.  This  practice,  as  will  be  mentioned,  is 
important  in  irritable  vagina,  etc. 


GENERAL  REMARKS. 

The  treatment  of  nervous  affections  demands  much  study  and 
great  attention  on  the  part  of  the  practitioner.  The  symptoms 
differ  in  every  individual,  and  vary  even  in  the  same  person. 
The  pain  and  distress  of  to-day  constitute  not  the  trouble  of  the 
morrow ;  and  eYerj  new  sensation  is,  to  the  timid  and  suffering 
woman,  the  evidence  of  a  new  disease,  and  the  harbinger  of  new 
dangers.  The  most  dire  maladies  are  confidently  anticipated ;  and 
the  reaction  of  such  apprehensions  on  the  nervous  system  and  the 
mind  of  the  patient  greatly  aggravate  all  her  sufferings. 

It  is  not  right  to  suppose  that  the  patient  can  avoid  all  this,  by 
the  simple  exertion  of  her  will.  The  complaints  are  essentially 
physical.  The  mental  and  moral  disturbances  are  secondary :  for 
the  brain,  the  organ  of  the  mind,  disturbed  by  physical  causes,  is 
"out  of  tune;"  thence  all  its  functions,  mental  and  moral,  as  well 
as  physical,  are  more  or  less  impaired.  Remove  the  cause,  correct 
the  physical  state  of  this  great  nervous  centre,  and  the  apprehen- 
sions and  anxieties  of  the  patient  will  be  dissipated,  her  cloudy 
and  perplexed  mind  will  become  clear  and  discriminating.  The 
dark  world  will  again  be  pictured  with  scenes  of  joy  and  happi- 
ness ;  and,  earnestness  and  zeal  will,  once  more,  cheerfully  impel 


282  TREATMENT    OF    IRRITABLE    UTERUS. 

her  to  the  discharge  of  every  duty  to  her  Creator  and  Benefactor, 
as  well  as  to  her  fellow-beings. 

True,  however,  as  are  these  propositions,  neither  physician  nor 
patient  must  lose  sight  of  the  apparently  opposite  truth,  namely, 
that  the  mind  influences  the  body  for  good  or  evil.  Mental  and 
moral  affections  are  often  the  sole  causes  of  disease,  and  very 
often  aggravate,  and  not  unfrequently  relieve,  existing  complaints. 
The  state  of  the  "morale"  is  an  important  agent  in  etiology  and 
therapeutics.  It  is  thought  that  persons,  of  a  powerful  and  de- 
termined will,  have,  by  mental  effort,  recovered  from  diseases 
which  otherwise  would  have  proved  fatal.  However  true,  there- 
fore, that  the  essential  character  of  nervous  affections  is  physical, 
however  freely  this  truth  may  be  enunciated,  and  however  ten- 
derly and  charitably  the  interesting  sufferers  should  be  treated; 
nevertheless,  their  mental  and  moral  sentiments  must  be  carefully 
but  decidedly  addressed  by  the  scientific  physician.  They  must 
be  taught  and  urged  to  exert  all  their  spiritual  energies  in  oppo- 
sition to  their  corporeal  sensations. 

These  efforts  will  be  useful  not  only  negatively,  in  removing 
additional  sources  of  mischief  from  mental  and  moral  depression, 
but  positively,  in  giving  the  best  possible  stimulus  to  nervous 
power.  So  much  benefit  has  resulted  from  mental  excitements, 
so  many  nervous  patients  have  been  resuscitated  from  their 
wretched  exhausted  condition  by  a  change  of  circumstances 
forcing  them  to  exertion,  that  the  unphilosophical  conclusion 
has  often  been  made,  and  needs,  therefore,  often  to  be  refuted — 
that  the  character  of  the  complaint  was  moral,  not  physical. 

The  practitioner  devoted  to  nervous  patients  must,  therefore, 
be  also  the  metaphysician  and  the  moralist.  His  therapeutics 
must  often  be  of  a  spiritual  character.  He  must  gain  the  confi- 
dence of  his  patient,  and  induce  her  to  believe  his  word  rather 
than  her  own  bodily  sensations;  to  act  in  opposition  to  her  feel- 
ings ;  to  be  governed,  not  by  her  corporeal  state,  but  by  reason 
and  conscience ;  and  to  carry  her  thoughts  away  from  her  trials, 
to  things  around,  above,  and  beyond  her  mere  animal  nature. 
He  should  not  only  stimulate  and  divert  her  mind  and  heart  by 
his  own  presence  and  conversation ;  but  he  should  call  to  his  aid 
her  friends,  her  companions,  her  intellectual  and  religious  moni- 
tors, who  may  judiciously  change  the  current  of  her  thoughts, 
and  stimulate  her   whole    mental   and  moral   nature,  and  thus 


GENERAL    REMAKKS.  283 

greatly  contribute  to  the  restoration  of  nervous  power,  and  the 
consequent  diminution  of  morbid  irritability. 

Happy  is  the  physician  who  is  so  well  indoctrinated  in  physi- 
cal, mental,  and  moral  science  that  he  can  successfully  address 
himself  to  the  organic,  animal,  and  spiritual  nature  of  his  sensi- 
tive, delicate  sufferer!  And  thrice  happy  is  the  cultivated  and 
refined  lady  thus  restored  to  all  her  natural  delightful  sensations, 
and  to  all  her  mental  and  spiritual  enjoyments!  Words  are 
inadequate  for  the  expression  of  her  happiness,  or  her  gratitude 
to  him  who  has  been  the  instrument  of  so  great  a  blessing  as 
renovated  health  and  spirits. 


28i  TREATMENT    OF    COMPLICATIONS. 


CHAPTEU    XI. 

TREATMENT    OF    THE    COMPLICATIONS    OF    IRRITABLE 

UTERUS. 

MENSTRUAL  DISTURBANCES. 

The  symptoms  of  irritable  uterus  are  modified  by  the  men- 
strual function.  Every  month  there  is  an  additional  irritation, 
and  consequent  congestion. 

DysMENORRHOEA.  —  The  phenomena  of  irritable  uterus  are 
greatly  aggravated,  as  already  detailed,  every  month,  and  are 
then  known  as  ^^  Dysmenorrhoear  In  its  usual  uncomplicated 
condition,  dysmenorrhoea  is  nothing  more  than  an  acute  state  of 
"  nervous  irritation."  The  predisposing  cause  is  the  morbid  irrita- 
bility of  the  tissues  of  the  uterus,  which,  when  disturbed,  is  mani- 
fested by  neuralgic  pain,  spasms,  etc. 

During  the  interval^  attention  should  be  paid  to  the  predis- 
position. During  the  ■  paroxysm^  the  attempt  should  be  made  to 
diminish  the  sufferings  of  the  patient.  The  first  is  radical,  aiming 
to  destroy  the  morbid  state  of  the  uterus,  that  the  neuralgia,  etc., 
may  not  return;  the  second  is  merely  palliative. 

During  the  interval. — To  carry  out  the  radical  mode  of  treat- 
ment, the  cause  of  the  irritable  condition,  which  gives  rise  to 
dysmenorrhoea,  must  be  detected.  These  causes  are  various,  and 
should  be  carefully  investigated,  and  as  far  as  practicable  removed. 

The  two  most  frequently  met  with  are  displacements  of  the  uterus 
and  obstructions  in  the  cervix.  The  former  not  only  produces  ute- 
rine irritation,  but  is  very  often  the  cause  of  "flexion"  of  the  cer- 
vix, and  tbus  produces  a  partial  or  complete  constriction  of  the 
cervical  canal.  Hence,  when  the  menstrual  secretion  commences, 
the  fluid  has  no  ready  outlet.  It  accumulates  in  the  organ  and 
causes  irritation  and  spasm — a  true  labor.  When  the  obstruction 
by  this  efibrt  is  relieved,  and  the  discharge  flows  rapidly,  the  spasm 


DYSMENOREHCEA.  285 

and  pain  diminisli  and  disappear.  So  also  obstructions  arising 
from  thickened  mucus,  coagulable  lymph,  or  coagulated  blood, 
cause  usually  only  temporary  pains.  Hence,  it  is  very  common, 
especially  in  young  girls,  that  the  pain  is  very  evanescent, 
although  it  may  be  very  intense  for  two  or  three  hours,  or  even 
for  ten  or  twelve ;  but  it  subsides,  and  the  rest  of  the  period  is 
passed  with  little  suffering.  If  there  be  a  deformitj^,  or  a  thick- 
ened condition  of  the  cervix,  or  of  the  mucous  membrane  alone, 
a  decided  permanent  stricture,  or  an  encroachment  on  the  canal 
by  a  tumor  in  the  walls,  then  the  pain  is  more  intense,  and  endures 
through  the  whole  period. 

All  these  obstructions  should  receive  attention,  and  be  obviated 
by  surgical  means,  or  at  least  diminished.  All  inflammation, 
therefore,  must  be  removed,  and  the  deformities  and  strictures  be 
overcome  by  sponge  tents  and  bougies,  or  perhaps  by  the  knife. 

The  treatment  by  bougies,  originally  recommended  by  Dr. 
Macintosh,  is  ordinarily  successful.  If,  however,  the  uterus  be 
in  its  natural  position,  and  especially,  if  the  woman  has  never 
borne  children,  it  is  almost  impossible  to  use  straight  bougies. 
They  should  have  a  curve  similar  to  that  of  the  uterine  sound, 
and  should  be  made  of  some  slightly  flexible  metal ;  the  best  is 
pure  silver,  which  while  it  can  be  readily  bent,  is  sufficiently  firm 
to  retain  its  form  during  the  operation.  This  dilatation  can  per- 
haps always  be  accomplished  by  beginning,  as  in  cases  of  stric- 
tures of  the  urethra,  with  small  bougies,  and  gradually  employing 
larger  instruments. 

In  chronic  cases  this  process  is  slow,  and  two  additional  sug- 
gestions Lave  been  made  by  Prof.  Simpson,  first  by  allowing  the 
bougie,  in  the  form  of  an  intra-uterine  pessary,  to  remain  for  some 
days ;  on  the  removal  of  which  a  larger  one  can  be  introduced. 
Secondly,  he  proposes  in  certain  instances  to  make,  by  means  ot 
the  "bistouri  cache  or  hysterotome,"  an  incision  along  the  length 
of  the  cervix  from  the  internal  to  the  external  os  uteri,  first  on 
one  side  and  then  on  the  opposite,  and  increase  its  depth  as  the 
blade  is  withdrawn,  so  as  to  involve  the  whole  thickness  of  the 
cervix  at  its  lower  extremity.  The  authority  of  Sir  James  Y. 
Simpson  is  deservedly  so  great  that  what  he  recommends  is  im- 
mediately reduced  to  practice  by  a  large  number  of  the  profession. 
We  cannot  believe,  however,  that  either  of  the  above  suggestions 
are  free  from  the  most  serious  evils.  That  they  may  be  occasionally 


286  TREATMENT    OF    COMPLICATIONS. 

successful  there  can  be  but  little  doubt  from  the  testiraony  ad- 
vanced ;  but  we  firmly  believe  that  the  same  relief  can  be  afforded 
almost  universally  by  safer  measures.  The  intra-uterine  stem  is 
certainly  a  source  of  irritation,  not  merely  to  the  nerves  of  the 
uterus,  but  to  its  organism.  Hence,  not  only  pain,  but  congestions 
followed  by  hemorrhages  and  leucorrhoea,  and  also  by  inflamma- 
tion, frequently  result.  Much  testimony  also  has  been  adduced 
to  prove  that  great  danger  has  resulted  to  the  health  and  the  life 
of  the  patient  by  the  extension  of  the  inflammation  to  the  sub- 
stance of  the  uterus  and  to  the  peritoneum,  and  that,  in  some  in- 
stances, actual  perforation  of  the  uterus  has  taken  place. 

As  to  the  knife,  the  practice  of  Prof.  Simpson  has  been  and  still 
is  very  extensively  imitated.  A  variety  of  uterotomes  have  been 
suggested,  and  much  discussion  ensued  as  to  the  location  of  the 
obstruction,  whether  it  be  at  the  internal  or  external  os  uteri,  or 
in  some  other  portion  of  the  cervical  canal.  The  depth,  also,  of 
these  incisions  has  been  varied ;  some  contending  simply  for  a 
division  of  the  mucous  membrane,  and  others  that  the  incision 
should  extend  to  the  proper  tissue  of  the  neck ;  while  others 
again  boldly  recommend  the  free  division,  in  a  lateral  direction, 
of  the  vaginal  portion  of  the  cervix,  and  even  the  amputation  of 
one  or  both  lips  of  the  cervix,  so  as  to  make  a  free  exit  for  the 
menses,  or  to  remove  some  supposed  deformity  of  the  neck. 

It  would  perhaps  be  presumptuous  to  stigmatize  such  operations 
as  almost  universally  unnecessary,  cruel,  and  dangerous,  only  to 
be  justified  when  there  is  some  actaal  deformity  of  the  cervix,  or 
total  occlusion  of  the  canal,  causing  a  retention  of  the  menses. 

It  seems  to  be  forgotten  that  in  the  virgin  condition  the  pas- 
sage through  the  cervix  is  always  small,  and  yet  ordinarily  the 
menses  are  excreted  with  little  or  no  trouble,  and,  in  case  of 
marriage,  fecundation  readily  ensues.  Hence,  if  there  be  room 
for  the  introduction  of  the  uterotonie,  it  is  to  be  presamed  that 
there  can  be  no  great  morbid  constriction  which  cannot  be 
overcome  by  simple  dilatation,  which  is  far  less  painful  and 
dangerous.  The  operation  with  the  knife  is  painful ;  it  is  often, 
productive  of  serious  hemorrhage,  and  the  incision  has  often 
unwittingly  been  extended  so  deeply  as  to  divide  the  peritoneal 
covering,  or  at  least  to  excite  inflammation,  even  fatal  in  this 
delicate  tissue.  In  less  severe  operations,  the  inflammation  is 
not  unfrequently  troublesome,  and  the  incision  of  the  mucous 


DYSMEXORKHCEA.  287 

membrane  will  be  followed  by  a/cicatrix;  and  thus,  if  care  be 
not  taken,  the  contraction  of  tbe  tissues  may  be  increased;  or  if 
the  cut  surfaces  be  kept  asunder,  the  scar  will  be  larger,  and 
hence  mischief  may  result  in  cases  of  pregnancy  and  parturition. 
Such  disadvantages  and  dangers  ought  not,  we  think,  to  be 
incurred  for  the  relief  of  the  pain,  which  occurs  but  once  in  four 
weeks,  which  exists  but  for  a  few  hours,  and  which  can  be  very 
generally  palliated  by  appropriate  treatment.  In  the  opinion 
also  of  a  large  number  of  the  profession,  dilatation  by  wax  or 
metallic  bougies  is  equally  efficacious,  and  far  less  dangerous. 
This  has  been  our  own  constant  experience;  we  have  never 
thought  it  necessary  to  resort  to  the  knife,  neither  have  we 
failed,  if  a  small  probe  could  be  introduced  into  the  uterus,  in 
accomplishing  a  sufficient  dilatation  by  bougies;  thus  preserving 
intact  the  mucous  membrane  free  from  any  cicatrices  or  new 
formed  tissues. 

If  we  can  judge  from  our  own  experience,  which  has  now 
extended  through  some  forty  years,  strictures  of  the  neck  of  the 
uterus  are  exceedingly  rare,  notwithstanding  all  that  has  been 
written  respecting  their  frequency  and  their  proper  management. 
The  mal-positions  of  the  uterus  are  so  frequently  attended  with 
curvatures  of  the  lower  part  of  the  body,  and  the  different  por- 
tions of  the  neck  of  the  uterus,  that  the  distortions,  thus  produced, 
have  given  rise  to  obstructions,  which  have  been  mistaken  for 
contraction  or  strictures.  Post-mortem  examinations  have  seldom 
verified  the  supposed  existence  of  preternatural  narrowness  of 
the  canal.  The  attempt  to  introduce  a  bougie  is  often  very  diffi- 
cult, especially  to  the  inexperienced;  its  point  often  impinges 
against  the  rugosities  of  the  arbor  vitse,  while  the  flexures  of  the 
canal  will  often  entirely  arrest  the  progress  of  the  sound.  Hence, 
the  whole  difficulty  will  often  vanish  by  giving  a  different  direc 
tion  to  the  point,  so  as  to  avoid  the  ruga?,  of  the  canal,  or  by 
relieving  the  mal  position  of  the  whole  organ  the  flexion  of  the 
neck  disappears,  and  the  sound  enters  without  farther  difficulty. 
At  least,  this  is  our  experience,  and  we  must  refer  the  reader  to 
further  observations  on  this  subject  to  what  has  been  said  on 
mechanical  dysmenorrhcea  and  flexions  of  the  uterus. 

The  displacements  must  be  treated  by  suitable  pessaries,  that 
is,  by  those  which  cause  no  pressure  on  the  cervix,  and  which  can 
be  worn  for  months  without  themselves  exciting  pain  or  irrita- 


288  TREATMENT    OF    COMPLICATION'S. 

tion.  Under  these  circumstances  pessaries  are,  in  our  liands,  by 
far  the  most  efficient  means  for  the  radical  treatment  of  most 
forms  of  dysmenorrhoea.  They  relieve  the  displacement  and  also 
the  flexion  of  the  neck.  No  mechanical  obstruction  remaining, 
the  sensitiveness  gradually  diminishes.  The  predisposition  is 
destroyed,  and  the  consequences  disappear. 

The  flexion  of  the  uterus,  so  frequently  the  cause  of  dysmenor- 
rhoea, is  a  cause  also  of  sterility  in  many  young  married  women, 
by  preventing  the  entrance  of  the  semen  to  the  cavity  of  the 
uterus.  Few  results  have  been  more  gratifying  than  to  discover 
that  in  such  cases,  pessaries  not  merely  relieve  the  pain  and 
spasms  of  dysmenorrhoea,  but  facilitate  conception. 

During  the  absence  of  the  catamenia,  the  whole  treatment  indi- 
cated for  irritable  uterus  is  more  or  less  applicable,  such  as  good 
diet,  exercise  out  of  doors,  tonics,  and  particularly  the  use  of  cold 
water  internally  and  externally. 

During  the  paroxysm. — As  soon  as  there  are  any  indications  pre- 
monitory of  the  menses,  and  the  acute  symptoms  of  irritation  are 
expected,  the  whole  treatment  is  to  be  reversed;  and  palliation  of 
the  suffering  becomes  the  chief  object.  The  bowels  should  be 
wxll  opened  by  a  nauseating  laxative,  as  the  Oleum  ricini,  or  by 
an  enema ;  the  patient  should  be  placed  in  bed,  after  a  hot  pedi- 
luvium,  hip,  or  general  bath.  Poultices  and  fom.entations  to  the 
hypogastrium,  hot  applications  to  the  feet,  and  mucilaginous  and 
warm  vaginal  injections  should  be  employed,  followed  by  the 
exhibition  of  hot  drinks,  and  diaphoretics. 

Sometimes  mild  rubefacients  may  be  employed,  and  if  much 
pain,  narcotics  should  be  given. 

Camphor  is  very  universally  tolerated,  and  so  also  are  hyos- 
cyamus,  lactucarium,  and  belladonna.  Opium  and  its  numerous 
preparations  are  the  most  efi'ectual  of  all  the  anodynes;  but  they 
are  so  frequently  the  sources  of  immediate  distress  to  nervous 
women,  and  when  often  repeated  in  protracted  cases,  have  such 
dire  consequences  on  the  body  and  mind  of  the  patient,  that  the 
practitioner  should  be  prudent  in  their  use,  should  omit  them  as 
soon  as  possible,  and  carefully  warn  his  patient  as  to  their  abuse. 
"When,  unfortunately,  a  habit  of  the  constant  employment  of  this 
drug  is  generated,  great  judgment,  firmness,  and  perseverance  are 
requisite  to  accomplish  its  abandonment.     It  is  the  duty  of  the 


MENORRHAGIA.  289 

physician  and  friends,  however,  to  destroy  this  habit ;  and  it  can 
he  done  safely  and  rapidly  in  a  large  majority  of  cases. 

The  same  caution  should  be  exercised  as  regards  many  of  the 
powerful  narcotics,  sedatives,  and  anassthetics,  which  modern 
observation  and  science  are  rendering  so  familiar  to  the  practi- 
tioner. The  cannabis  Indica,  aconitia,  veratria,  and  the  inhalation 
of  ether,  and  of  chloroform,  however  occasionally  useful,  or 
however  frequently  to  be  employed  as  temporary  remedies,  must, 
if  continuously  taken,  be  regarded  as  deleterious.  Powerful 
impressions  on  the  nervous  system,  whether  from  mental  or 
physical  causes,  are  not  made  with  impunity.  There  is  more  or 
less  of  a  collapse  afterwards ;  more  or  less  increase  of  nervous 
susceptibility.  On  some,  a  great  shock  once  made  leaves  its 
impression  for  life. 

Stimuli. — These,  when  freely  given,  have  an  anodyne  influence, 
and  are  therefore  readily  resorted  to  by  the  poor  nervous  patient 
and  her  sympathizing  friends,  and  sometimes  they  cannot  be  pro- 
hibited for  the  time  being;  but  if  continued  they  inevitably  do 
mischief,  exhausting  the  vital  power,  and  increasing  the  irrita- 
bility of  the  tissues  local  and  general.  The  inebriate  becomes 
weak,  exhausted,  "  broken  down ;"  by  repeating  his  draught  he 
is  excited,  comforted,  and  apparently  strengthened ;  but  he  sinks 
to  a  lower  grade  of  weakness  and  exhaustion,  until  finally  he 
collapses  and  perishes.  This  is  true  of  minor  degrees  of  stimu- 
lation ;  the  nervous  woman  who  continually  resorts  to  brandy  or 
whiskey  for  sensations  of  weakness,  faintness,  distress  or  pain, 
will  most  assuredly  find  not  only  that  larger  and  more  frequent 
draughts  will  be  demanded,  but  that  her  vital  powers  will  be 
diminished  and  her  morbid  sensibility  continually  aggravated. 

Stimulation^  by  itself]  gives  no  strength:  it  is  at  best  but  a  palli- 
ative remedy,  and  cannot  be  relied  upon  for  any  radical  improve- 
ment. 

Menorrhagia. — Though  often  treated  as  the  result  of  debility, 
menorrhagia  is  doubtless,  as  maintained  in  this  work,  the  result 
of  irritation  in  almost  every  case,  whether  the  patient  be  in  an 
asthenic  or  sthenic  condition,  in  a  state  of  excitement  or  exhaus- 
tion. There  is  some  local  irritant,  though  often  apparently 
trifling,  and  there  is  usually  much  morbid  irritability.  This  pre- 
disposition existing,  any  additional  irritation,  as  the  menstrual 
19 


290  TREATMENT    OF    COMPLICATIONS. 

nisiis,  excites  congestion ;  tlience  increased  secretion — menor- 
rliagia — or  even  effusion  of  blood — hasmorrliagia.  The  usual 
treatment,  therefore,  by  tonics,  stimuli,  and  astringents,  b}''  cold 
water  externally  and  internally,  by  travelling  by  sea  or  land,  is 
but  palliative.  It  does  good  by  resisting  the  exhausting  effects 
of  the  discharge,  but  it  has  no  effect  on  the  local  irritation,  which 
is  the  "ipse  morbus;"  this  remains  intact. 

Removal  of  the  Local  Irritation. — Therefore,  while  attention 
should  at  all  times  be  paid  to  the  general  health  of  the  patient, 
and  while  any  tendency  to  asthenia  should  be  obviated  by  tonics, 
nutritious  diet,  cool  bathing,  and  other  hygienic  measures;  yet 
the  main  object  should  be  the  removal  of  the  local  irritation  and 
congestion. 

The  local  irritant  must  be  detected  and  relieved. 

If  any  decided  inflammation  be  found,  appropriate  local  mea- 
sures are  important ;  but,  perhaps,  the  caution  may  not  be  useless, 
that  in  all  cases  of  chronic  menorrhagia,  even  when  dependent  on 
phlogosis,  general  antiphlogistics  are  inadmissible.  The  whole 
system,  vascular  and  nervous,  is  already  too  much  exhausted, 
and  demands  nutritious  diet,  tonics,  etc.  So  far  from  these  endan- 
gering the  increase  of  inflammatory  action,  they  will  have,  indi- 
rectly, an  opposite  and  beneficial  influence  by  imparting  tone  and 
augmenting  the  efficacy  of  the  "  vis  medicatrix  naturas." 

If  displacements  of  the  uterus  be  found,  even  of  a  moderate  de- 
gree, they  must  be  removed.  They  are  the  most  frequent  cause 
of  chronic  menorrhagia,  according  to  our  experience ;  and  hence, 
the  permanent  restoration  of  the  organ,  by  pessaries,  is  more 
frequently  and  more  decidedly  useful  than  any  other  mode  of 
treatment.  It  relieves  the  irritation,  and  of  course,  the  conges- 
tion, which  is  the  pabulum  of  the  discharge.  It  is  most  gratifying 
to  find  that  during  the  employment  of  pessaries,  the  miserable 
and  neuralgic  sensations  of  the  exhausted  anoamic  woman  rapidly 
disappear,  and  hope  again  reanimates  the  frame;  while  day  after 
day  a  richer  blood  courses  through  the  round  of  the  circulation, 
imparting  nutrition,  strength, ,  vigor,  and  flesh,  and  the  counte- 
nance beams  forth  under  the  delightful  sensations  of  a  renovated 
existence. 

These  same  principles  and  treatment  by  means  of  pessaries  are 
aoplicable  not  only  to  such  cases  in  which  the  displaced  uterus 
is  simply  irritated  without  any  alteration  of  its  structure,  but  also 


MENOERHAGIA.  291 

to  a  very  large  number  of  cases,  generally  menorrhagic,  occa- 
sionally hemorrhagic,  which  arise  from  enlargeynents  of  the  womb, 
whether  hypertrophic  or  indurated,  or  dependent  on  tumors  in 
the  walls  or  on  the  exterior  surface  of  the  uterus.  Of  course, 
polypi  and  polypoid  growths  on  the  interior  of  the  organ  are  not 
embraced  in  this  statement. 

We  regard  very  few  practical  mistakes  greater  than  treating 
any  or  all  such  cases  as  inflammatory.  Pain  exists,  it  is  true,  not 
only  in  the  uterus  but  in  various  other  parts,  and  frequently  of 
the  most  intense  character ;  but  this,  it  should  be  remembered, 
often  exists  without  inflammation.  In  these  cases  it  is  dependent 
mainly  on  pressure.  Eelieve  the  pressure  and  the  pain  diminishes 
and  disappears. 

Case. — Thirty  years  ago  we  attended  a  lady,  then  thirty- eight 
years  of  age,  who  had  been  treated  by  the  late  Drs.  Physick  and 
Dewees  for  metritis,  from  which  she  apparently  recovered.  Some 
of  the  symptoms  returning,  and  Dr.  Dewees  being  absent,  we  took 
charge  of  her  case.  The  womb  was  found  enlarged  and  indu- 
rated from  the  previous  inflammation,  and  accompanied  by  the 
usual  symptoms  of  an  irritable  displaced  uterus.  These  were  re- 
lieved by  a  pessary,  which  was  worn  for  some  two  years  and  then 
removed.  Her  health  remained  excellent  until  March,  1857; 
when,  after  some  unusual  exertion,  she  was  seized  with  intense 
pain  in  the  left  hip,  down  the  thigh,  and  in  the  lower  part  of  the 
abdomen,  etc.,  with  more  or  less  nausea  and  disorder  of  her  diges- 
tive organs.  Her  friends  and  even  her  physicians,  one  of  whom 
considered  it  as  a  decided  case  of  carcinoma,  became  alarmed.  In 
August  we  were  called  to  see  her,  and  upon  examination  we  found 
the  indurated  uterus  still  large  and  heavy,  without  any  other  lesion 
than  a  partial  retroversion  towards  the  left  sacro-sciatic  notch. 
Our  prognosis  was,  therefore,  very  favorable,  and  afforded,  at 
once,  mental  relief  to  the  patient  and  her  friends.  Subsequent 
treatment  fully  confirmed  the  truth  of  this  prognosis. 

This  is,  perhaps,  not  the  place  to  more  than  allude  to  another 
opinion,  not  so  easily  demonstrated  as  the  one  just  mentioned,  and 
requiring  a  great  array  of  facts,  and  a  most  extensive  and  com- 
bined experience  to  verify ;  but  which  we  verily  believe  to  be 
true,  and  it  has,  for  very  many  years,  successfully  guided  our  own 
practice.  The  general  declaration  may  be  made,  admitting  some 
few  exceptions  from  accidental  causes,  and  from  peculiar,  specific, 


292  TREATMENT    OF    CO  MTLIC  A  TI  OXS. 

or  even  malignant  tendencies,  tliat  cdmormal  enlargemenU  of  the 
uterus,  and  the  tniaors  so  frequently  found  imbedded  in  its  sub- 
stance, or  implanted  on  its  exterior  surface,  are,  ^je?-  se^  innoxious. 
They  form  without  the  knowledge  of  the  patient  or  physician ; 
they  often  exist  for  many  years,  and  grow  to  a  great  size  without 
the  consciousness  of  the  patient;  they  are  frequently  first  detected 
in  post-mortem  examinations  of  women  who  have  died  from  other 
diseases,  and  even  when  so  numerous  as  to  attract  attention  dur- 
ing life,  have  been  carried,  in  cases  that  we  have  known,  for 
twenty  and  forty  years  with  impunity. 

So,  also,  ovarian  tumors^  when  not  complicated  with  dropsy,  we 
have  found  to  be  usually  of  the  same  harmless  character.  In  all 
such  cases,  there  may  be  occasionally  great  suffering,  and  some- 
times great  apparent  danger.  These  serious  symptoms  have  often 
been  attributed  to  active  disease  in  the  tumors,  and  have  been 
supposed  to  depend  upon  their  degeneration.  This  is  rarely,  how- 
ever, the  case;  very  generally  the  symptoms  are  neuralgic,  not 
inflammatory,  and  arise  merely  from  weight  and  pressure.  Irri- 
tation, not  only  of  the  uterus,  but  of  the  anterior  crural,  obtura- 
tor, sacral,  and  other  nerves,  is  excited;  hence  arises  the  irrita- 
bility of  the  womb,  of  the  pelvic  nerves,  of  the  spinal  marrow 
and  brain,  with  the  usual  secondary  consequences.  Hence,  also, 
congestions  of  the  uterus,  menorrhagia,  and  hasmorrhagia,  are 
consequences  which  often  ensue,  and  not  only  increase  the  debi- 
lity of  the  patient,  but  aggravate  her  nervous  sufferings.  Even 
in  such  cases  of  severity,  death  seldom  results  under  any  suitable 
treatment. 

These  neuralgic  symptoms  and  their  consequences  are  more  fre- 
quently met  with  when  the  tumors  are  comparatively  small;  for 
then  they  occupy  the  pelvic  cavity,  and  irritate  the  large  nerves 
of  this  passage :  but  when  the  tumors  are  so  large  as  to  rise  out 
of  the  pelvis,  like  the  uterus  at  the  fourth  month  of  utero-gesta- 
tion,  all  unpleasant  symptoms  usually  disappear,  and  the  patient 
may  enjoy  excellent  health  for  years. 

All  of  these  enlarged  growths  are,  therefore,  not  directly,  but 
indirectly,  injurious.  In  themselves  they  give  rise  to  no  irrita- 
tion ;  but  cause  irritability  by  pressure  on  sensitive  tissues,  dis- 
turbing their  functions,  and  thus  they  secondarily  do  mischief. 

The  treatment,  therefore,  of  the  preternatural  discharges  from 
the  uterus,  dependent  upon  hypertrophic  and  other  enlargements. 


MENORRHAGIA    FROM    TUMORS,    ETC.  293 

should  be  predicated  on  this  principle.  By  relieving  the  pres- 
sure, the  irritation,  the  neuralgia,  the  congestions,  and  the  dis- 
charges, often  disappear.  Bj  good  diet,  tonics,  exercise,  and  cool 
water,  the  general  system  is  strengthened,  and  the  patient  will 
usually  be  restored  to  health,  though  the  morbid  enlargements 
may  remain  unaltered  for  years.  "When  menorrhagia  or  hemor- 
rhagia  is  connected  with  the  presence  of  fibrous  tumors  of  the 
uterus,  much  success  in  our  hands  has  attended  the  above  des- 
cribed treatment:  nevertheless,  these  discharges,  although  dimi- 
nished, are  not  always  completely  checked,  especially  when  the 
tumors  are  large.  There  is  so  much  determination  to  the  uterus, 
not  merely  from  the  irritation  arising  from  the  weight  and  dis- 
placement of  the  organ,  but  also  from  the  presence  of  the  tumors, 
that  the  periodical  flows  are  enhanced,  and  often  continue  more 
abundant  than  natural  during  the  menstrual  life:  still,  few  bad 
effects  comparatively  ensue;  and,  in  most  instances,  patients, 
when  properly  treated,  are  able  to  take  air  and  exercise,  are  free 
from  much  suffering,  and  frequently  gain  flesh  and  strength,  and 
are  able  to  partake  of  their  usual  social  enjoyments. 

Perhaps  these  views  may  appear  to  be  novel,  and  far  too  sweep- 
ing, but  we  present  them  with  much  confidence,  for  they  have 
been  tested  in  a  great  variety  of  cases,  and  during  many  years. 
Large,  as  well  as  small  tumors,  whether  uterine  or  ovarian,  have 
ceased  to  excite  irritation,  when  by  means  of  pessaries,  pressure 
has  been  removed  from  important  organs.  Of  course  cases  will 
at  times  be  met  with,  where  active  inflammation  in  the  tumors,  or 
the  adjacent  organs,  alters  the  whole  character  of  the  complaint, 
and  renders  them  imminently  dangerous.  In  other  cases,  espe- 
cially when  long  protracted,  hemorrhagic  discharges,  or  various 
complications,  may  arise  from  local  or  general  disease,  and  scro- 
fulous or  cancerous  tendencies.  These  are  strictly  complications, 
and  are  comparatively  rare. 

If  there  be  any  truth  in  the  views  now  presented,  the  utter 
inefiiciency  of,  and  the  positive  mischief  resulting  from,  rest,  low 
diet,  evacuating,  and  other  exhausting  processes  for  the  discussion 
of  heterologue  tumors  of  the  uterus,  must  be  apparent.  Nothing 
also  can  be  anticipated  from  a  perseverance  in  the  employment 
of  alteratives,  including  the  whole  list  of  narcotics,  arsenical  and 
mercurial  medicines,  in  all  the  innumerable  combinations  by  which 
they  have  been  exhibited.     Even  iodine,  on  which  so  much  de- 


294  TREATMENT    OF    COMPLICATIONS, 

pendence  has  been  placed,  usually  fails  in  making  any  impression 
on  these  new  formations. 

If  it  be  true  .that  such  tumors  often  exist  for  years  without 
being  recognized  and  the  woman  remains  in  good  health  ;  if  they 
may  be  carried  for  thirty  or  forty  years  with  impunity,  and  occa- 
sionally diminish  and  disappear,  in  the  progress  of  life ;  if,  when 
bad  consequences  result,  they  are  almost  universally  of  a  nervous 
and  not  inflammatory  character ;  and  if  the  occurrence  of  inflam- 
mation or  malignity  be  rare  exceptions  in  their  history ;  surely, 
there  is  no  justification  for  resorting  to  the  knife  of  the  surgeon 
to  extirpate  such  tumors.  It  is  difficult  to  imagine  on  what  sci- 
entific ground  the  neck  of  the  uterus  has  been  dilated,  or  incised, 
the  tumors  laid  open,  as  recommended  by  I.  Baker  Brown,  Esq., 
or  "  enucleated"  as  practised  in  this  city  by  Dr.  Washington  L. 
Atlee,  their  cysts  pencilled  with  caustic,  and  even  the  operation 
of  gastrotomy  performed,  in  order  to  remove  these  tumors  from 
the  surface  or  the  tissues  of  the  uterus ! 

Such  things  have  been  done,  and  have  been  reported  sometimes 
as  successful,  and  sometimes  acknowledged  as  fatal.  If  the  sur- 
gical principle  be  at  all  correct,  that  the  less  is  to  be  preferred  to 
the  greater  evil ;  that  the  life  of  the  patient  should  not  be  posi- 
tively endangered  to  eradicate  a  disease  not  necessarily  fatal, 
all  these  operations  for  abnormal  growths  of  the  uterus  are  far 
from  being  justifiable. 

Palliative  Measures. — Although,  in  the  treatment  of  menor- 
rhagia,  the  main  indication  is  the  removal  of  the  cause ;  yet  when 
the  discharge  is  severe  or  persistent,  additional  measures  may  be 
important.  Not  only  a  tonic  treatment  but  even  stimulants  may 
at  times  be  demanded.  Internal  astringents,  also,  have  been 
freely  given,  but  have  generally  failed  to  arrest  the  discharge. 
Secale  cornutum  in  its  various  preparations  has  been  found  very 
useful,  and  may  be  given  as  well  during  the  interval  as  during 
the  flow. 

Locally,  the  practitioner  may  resort  to  cold  applications  to  the 
lower  part  of  the  abdomen  when  the  discharge  is  protracted  and 
the  patient  exhausted ;  he  should  take  care,  however,  to  preserve, 
at  the  same  time,  the  warmth  of  the  extremities.  Cold  water 
may  also  be  thrown  into  the  rectum  and  even  into  the  vagina. 

There  can  be  no  doubt,  in  some  cases,  that  advantage  may  be 
derived  from  hot  water,  as  several  of  our  patients  affirm  that  they 


LEUCORRHGEA.  295 

can  always  check  the  discharge  hy  washing  in  warm  water.  Dry 
heat,  however,  is  far  more  efficient.  Hence,  the  application  of 
bottles  of  hot  water,  hot  bricks,  oats,  sand,  etc.,  to  the  lower 
extremities,  have  long  been  regarded  as  efficient.  Of  late,  how- 
ever, hot  water  in  bladders,  bags  of  caoutchouc,  or  in  tin  bottles, 
applied  to  the  anterior  or  posterior  parts  of  the  body,  are  strongly 
recommended.  Heat  acts  on  the  principle  of  revulsion ;  hence, 
other  revulsives,  as  sinapisms,  spirits  of  turpentine,  blisters, 
ginger,  and  cayenne  pepper  plasters,  etc.,  are  all  of  them  important. 
Acting  upon  the  same  principle,  is  the  application  of  cold  or  hot 
cloths  externally,  which,  by  coverings  of  oiled  silk  and  flannels, 
are  so  confined,  that  heat,  eruptions,  etc.,  are  excited. 

Assistance  will  also  be  derived  from  the  various  astrino;ent 
washes  to  the  vagina  and  cervix  uteri.  If  the  discharge  prove 
protracted  the  tampon  may  be  employed,  either  alone  or  satu- 
rated with  astringent  solutions.  This  tampon,  although  some- 
times successful,  cannot  be  relied  upon  in  cases  of  hemorrhage. 
In  chronic  cases,  advantage  may  be  derived  in  some  instances 
from  the  occasional  passage  of  an  uterine  probe  or  bougie,  which 
is  supposed  to  act  by  promoting  the  contraction  and  condensation 
of  the  uterine  tissue.  In  very  obstinate  cases,  when  the  powers 
of  the  patient  are  sinking,  injections  may  be  thrown  into  the 
cavity  of  the  uterus;  tepid  water  is  usually  sufficient,  but  weak 
solutions  of  alum,  sulphate  of  zinc,  persulphate  of  iron,  or  other 
astringents  may  be  employed.  By  some,  solutions  of  nitrate  of 
silver  have,  also,  thus  been.  used.  Great  care,  however,  is  re- 
quired in  all  these  uterine  injections,  as  the  organ  is  intolerant  of 
the  presence  of  fluids  in  its  cavity,  and  hence  severe  pain,  spasms, 
and,  perhaps,  inflammation  might  be  excited.  In  the  opinion  of 
many,  there  is  still  greater  danger,  it  is  thought,  from  the  trans- 
mission of  the  fluid  through  the  Fallopian  tubes  into  the  cavity 
of  the  peritoneum,  thus  exciting  peritonitis. 

Leucorrhoea  is  another  complication  of  irritable  uterus,  which 
has  often  taxed  the  patience  and  science  of  the  physician. 

In  all  cases,  purely  inflammatory,  much  has  of  late  years  been 
done  by  attending  to  this  pathological  state,  and  prescribing  not 
merely  for  the  discharge,  as  had  been  the  custom,  but  for  the 
phlogosed  condition  of  the  tissues,  which  constitutes  the  real  dis- 
ease, of  which  the  discharge  is  the  mere  consequence. 


296  TKEATMEXT    OF    COMPLICATIONS. 

We  have,  however,  contended  that  this  inflammatory  state  is 
comparatively  imfrequent ;  and  that  the  cases,  usually  met  with 
in  practice,  under  the  various  names  of  weakness,  the  whites, 
fluor  albus,  leucorrhoea,  etc,  are  the  consequences,  not  of  phlo- 
gosis,  but  of  a  simple  congestive  state  of  the  uterine  tissues. 

Removal  of  the  Irritation. — We  have  also  illustrated  that  what- 
ever irritates  the  uterus  causes  congestion,  and  is  generally  fol- 
lowed by  a  red  or  white  discharge ;  and  that  this  white  discharge 
is  so  intimately  connected  with  disturbed  menstruation,  that  prac- 
tically it  may  be  regarded  as  a  white  menorrhagia.  Hence  the 
practice  already  indicated  for  chronic  menorrhagia  is  applicable 
to  this  functional  leucorrhoea.  Eemove  the  irritable  condition  of 
the  uterus  and  you  will  cure  the  leucorrhoea.  The  cause  being 
removed,  the  flow  ceases.  The  irritation  being  destroved,  there 
is  no  congestion,  and,  of  course,  no  increased  secretion  or 
effusion. 

As  displacements  are  so  commonly  the  cause  of  irritable  uterus 
and  its  consequences,  the  fact  that  pessaries  of  suitable  material, 
size,  and  form,  are  the  best  and  most  efficient  remedies  for  most 
cases  of  fluor  albus,  receives  a  philosophical  solution.  They 
strike  at  the  root  of  the  whole  mischief.  They  relieve  the  irrita- 
tion, and,  of  course,  the  congestion  and  the  discharge. 

Palliative  Measures. — All  the  usual  general  and  local  treatment 
for  an£Bmic  and  exhausted  cases  of  irritable  uterus,  are  important 
adjuvants  when  leucorrhoea  exists;  for  although  this  discharge 
is  not  the  result  of  weakness,  it  aggravates  the  exhaustion  by 
the  quantity  of  fluid  lost  to  the  system.  Here,  not  only  cold 
vaginal  injections,  but  almost  every  variety  of  astringent  and 
alterative  washes  will  be  very  useful,  and  contribute  to  hasten  a 
recovery.  In  some  unusual  cases  of  protracted  leucorrhoea,  with 
great  relaxation  of  the  uterine  tissue,  some  of  these  washes  may 
be  thrown  into  the  cavity  of  the  neck,  or  even  into  that  of  the 
body  of  the  uterus,  with  the  same  caution,  however,  as  in  analo- 
gous cases  of  protracted  menorrhagia. 

INFLAMMATION. 

In  the  treatment  of  cases  of  irritable  uterus,  complicated  with 
inflammation  at  the  external  orifice,  canal  or  cavity  of  the  uterus, 
great  judgment  and  prudence  are  demanded. 


INFLAMMATION.  297 

Acute  Inflammation  need  not  here  be  considered ;  all  prac- 
titioners agree  in  keeping  the  patient  quiet,  and  in  endeavoring 
at  once  to  subdue  inordinate  excitement  by  suitable  measures. 

Chronic  Inflammation. — In  cbronic  endometritis^  whether 
simply  in  the  cervix,  or  extending  into  the  interior  of  the  uterus, 
the  diflEiculty  of  diagnosis  is  often  great.  And,  even  when  the  ex- 
istence of  inflammation  is  positively  known,  it  is  still  more  diffi- 
cult to  determine  how  far  the  symptoms,  especially  the  pain  and 
spasms,  are  dependent  on  an  irritable  or  on  an  inflamed  state  of 
the  tissues,  on  a  displacement  of  the  uterus  it  may  be,  or  on  the 
mere  existence  of  phlogosis.  Or,  if  both  exist,  it  is  no  easy  matter 
to  establish  what  is  their  relative  influence  in  producing  the  secon- 
dary or  sympathetic  disturbances  of  the  system.  These  are  deli- 
cate C|uestions ;  but,  nevertheless,  they  are  of  vital  importance,  as 
has  been  frequently  urged  and  illustrated  in  these  pages. 

General  and  Local  Measures. — Without  recapitulation,  therefore, 
the  practical  conclusion  may  be  at  once  insisted  upon,  namely, 
that  while  every  moderate  and  judicious  effort  should  be  made  to 
overcome  such  inflammatory  congestions,  especially  by  rest,  warm 
vaginal  washes,  solutions — with  or  without  laudanum  or  morphia 
— of  borax,  of  alum,  of  the  sulphate  of  zinc,  of  the  sulphate  of 
copper,  of  the  nitrate  of  silver,  of  iodine,  etc.;  yet,  much  more 
will  generally  be  necessary  in  all  severe  attacks  of  uterine  affec- 
tion, especially  when  accompanied  by  spinal  and  cerebral  irrita- 
tions, with  their  severe  and  terrible  reflex  influences. 

Removal  of  the  Irritation. — If  the  principles  noAv  inculcated  be 
true,  precious  time  is  not  to  be  lost  with  mere  antiphlogistic  washes, 
or  "  caustic  touches."  Pressure  is  to  be  removed,  and  to  be  kept 
removed,  from  the  large  nerves  of  the  pelvis,  and  from  the  sensi- 
tive and  inflamed  cervix,  by  the  introduction  and  continued  use 
of  a  pessary,  although  the  inflammation  still  exists.  This  is  in 
opposition  to  received  views  and  practice ;  but  the  fears  of  using 
pessaries  have  arisen  from  the  destructive  character  of  their  mate- 
rials, their  improper  form  and  size.  When  suitably  constructed 
and  adjusted,  they  free  the  cervix  uteri  from  all  pressure  in  any 
direction,  and  so  far,  therefore,  from  aggravating  inflammatory 
action  in  its  tissues,  they  constitute  one  of  the  most  important  in- 
direct means  of  favoring  resolution,  for  they  prevent  the  constant 


298  TREATMENT    OF    COMPLICATIONS. 

pressure  and  attrition  of  the  delicate  sensitive  cervix  against  the 
posterior  walls  of  the  vagina. 

To  our  mind,  there  is  no  doubt  that  the  protracted  character  of 
these  superficial  inflammations  about  the  os  uteri,  together  with 
the  granular  condition  of  the  tissue,  and  the  so-called  ulcerations, 
existing  for  years  in  opposition  to  repeated  applications  of  lotions 
and  caustics,  are  maintained  by  the  constant  pressure  and  friction 
against  the  vagina,  as  it  lies  in  contact  with  the  rectum,  often  con- 
taining scybala.  Indeed,  such  attrition  may  truly  be  regarded,  in 
many  cases,  as  not  simply  an  aggravating,  but  as  an  original  cause 
of  these  cervical  lesions,  of  which  so  much  has  been  said  and  writ- 
ten. In  all  such,  and  many  analogous  cases,  some  variety  of  the 
ring-pessary  is  invaluable,  and  often  a  "sme  qua  non,''^  as  it  sup- 
ports the  uterus  at  the  root  of  the  neck,  and  thus  removes  all 
pressure  from  the  rest  of  the  cervix. 

All  these  observations  are  especially  applicable  to  those  cases 
where  there  had  been  even  severe  inflammation,  but  where  all 
the  phenomena  have  subsided,  and  those  of  irritable  uterus  alone 
remain. 


RHEUMATIC  AND  GOUTY  AFFECTIONS. 

The  treatment  of  irritable  uterus  complicated  with  rheumatic, 
arthritic  and  cutaneous  affections,  must  be  suitably  modified  by  the 
general  principles  regulating  metastatic  diseases  and  by  the  spe- 
cific treatment  which  each  form  of  disease  demands. 


SYMPATHETIC    AFFECTIO.VS.  2D9 


CHAPTER    XII. 

TREATMENT  OF  THE  COMPLICATIONS  OF  IRRITABLE  UTERUS 
—  Continued.     SECONDARY   AND   SYMPATHETIC   AFFECTIONS. 

A  TOLEEABLY  full  history  was  given  of  the  secondary  and  sym- 
'patlietic  symptoms  of  irritable  uterus^  in  order  to  illustrate  the  gene- 
ral, almost  universal,  influence  exerted  by  it;  to  assist  the  inexpe- 
rienced in  detecting  the  character  of  these  protean  complaints ;  to 
draw  broad  distinctions  between  them  and  the  inflammatory  dis- 
eases they  so  frequently  simulate ;  and  to  lay,  therefore,  a  good 
foundation  for  the  therapeutical  indications  and  treatment. 

In  their  management,  general  principles  will  be  sufficient  for 
the  educated  physician.  These  have  already  been  summed  up  in 
two  important  declarations.  First^  detect  and  remove  the  cause, 
if  practicable.  This  is  the  radical  treatment  of  all  spinal  and 
cerebral  irritations.  Secondly,  diminish  the  morbid  irritability 
of  the  cerebro-spinal  system,  by  imparting  tone  to  the  whole  body. 

The  well-informed  medical  practitioner  can  readily  make  any 
necessary  modification  of  the  treatment,  when  any  special  tissue 
or  organ  is  involved.  In  all  the  neuralgic  and  spasmodic  affec- 
tions of  the  muscles  of  the  extremities  and  of  the  body ;  in  all 
the  spinal  and  cerebral  affections ;  in  all  the  nervous  irritations  of 
the  face,  larynx,  oesophagus,  viscera  of  the  chest,  or  in  those  of  the 
abdomen ;  the  manifestations  will,  of  course,  be  very  diverse ;  but 
they  are  mere  varieties  of  nervous  irritation ;  the  essential  treat- 
ment is  the  same  in  all,  requiring  merely  judicious  and  scientific 
modifications,  according  to  the  tissues  or  organs  concerned. 

Great  care  in  forming  the  diagnosis  is  demanded.  The  frequent 
complication  of  nervous  with  functional  and  organic  diseases 
should  always  be  borne  in  mind ;  so  that,  while  the  latter  demands 
attention  the  former  may  not  be  neglected. 

Case. — The  author  was  lately  consulted  by  a  delicate  southern 
lady,  the  mother  of  several  children.  She  has  been  the  subject, 
for  five  years  of  piilmonary  symptoms,  with  cough  and  occasional 


300  TREATMENT    OF    COMPLICATION'S. 

h^emoptoe,  and  is  a  patient  of  a  professional  friend,  who  regards 
the  case  as  one  of  "  phthisis  incipiens."  She  complains  of  debility, 
oppression  about  her  chest,  neuralgic  pains,  and  weight  about  the 
pelvis.  Upon  a  vaginal  examination,  we  found  an  hypertrophied 
uterus,  which  was  prolapsed,  with  flexion  of  the  neck.  By  reliev- 
ing this  prolapsus,  her  other  sj^mptoms  were  greatly  palliated,  and 
she  could  take  much  more  exercise ;  so  that  not  only  was  there 
corporeal  relief,  but  much  hope  excited  that  her  life  might  be  con- 
siderably prolonged,  notwithstanding  the  decided  evidences  of 
tuberculosis. 

Such  instances  are  not  infrequent.  The  practitioner  who  ac- 
customs himself  to  analyze  and  arrange  the  phenomena  of  disease, 
is  often  surprised  to  find  how  large  a  portion  belongs  to  the  ner- 
vous system.  If,  instead  of  dismissing  them  with  some  tran- 
sient prescription,  it  may  be,  as  "nervous,"  he  should  treat  them 
as  veritable  and  important  realities,  having  their  own  type  and 
demanding  their  own  treatment ;  he  would  then,  not  unfrequently, 
be  agreeably  surprised,  by  discovering  that  symptoms  most  alarm- 
ing to  the  patient,  if  not  to  her  physician,  have  vanished,  that 
the  local  organic  disease  is  really  moderate,  and  that  an  excellent 
prospect  of  tolerable  health,  even  for  years,  may  be  rationally 
anticipated.  These  expectations  are  enhanced  by  the  fact  that, 
distressing  and  painful  nervous  irritations  being  dissipated,  a 
better  opportunity  is  afforded  for  conducting  the  treatment  of  the 
functional  or  organic  disease. 

These  views  should  enlarge  our  ideas  of  the  importance  of  the 
treatment  peculiar  for  nervous  diseases.  The  comfort,  the  happi- 
ness of  patients,  and  the  prolongation  of  life,  are  often  the  re- 
ward of  assiduous  scientific  attention,  even  in  incurable  diseases 
of  the  brain,  heart,  and  lungs.  Sometimes,  so  decided  is  the 
change  for  the  better,  that  the  patients  will  hardly  be  persuaded 
that  their  cases  are  still  critical  and  dangerous. 

The  consideration  of  these  facts,  in  connection  with  those  very 
frequently  met  with — where  mere  nervous  diseases  of  the  brain, 
larynx,  lungs,  heart,  liver,  alimentary  canal,  ovaries,  uterus,  etc., 
have  been  regarded  as  inflammatory  or  organic,  and  to  which 
"simulative  complaints"  such  constant  allusion  has  been  made — 
will  give  some  idea  of  the  mass  of  human  suffering  whicli  may 
be  mitigated  or  annihilated  by  a  careful  analj'-sis  of  the  morbid 


IRRITABLE    RECTUM.  301 

plienomena,  by  tracing  them  to  their  source,  by  eradicating  their 
causes,  and  by  a  judicious  adaptation  of  remedial  measures. 


IRRITABLE  RECTUM. 

The  symptoms,  causes,  diagnosis,  etc.,  of  irritable  rectum  have 
been  detailed. 

In  acute  cases  of  rectitis,  the  antiphlogistic  treatment,  with  due 
restrictions,  must  be  employed. 

But  in  chronic  cases  of  irritable  rectum,  where  there  is  great 
suffering  and  no  decided  marks  of  inflammation,  all  evacuating 
and  alterative  treatment  must  be  abandoned.  Laxatives  are  gene- 
rally requisite  to  soften  the  feculent  contents — not  to  purge — and 
thus  mitigate  the  suffering,  which  is  always  greatly  augmented  by 
either  a  fluid  or  indurated  stool.  Warm  hip-baths,  fomentations 
and  poultices  to  the  anus,  anodynes  and  liniments,  particularly  to 
the  sacral  region,  are  palliatives  of  importance.  When  they  can 
be  borne,  large  and  warm  mucilaginous  injections  to  the  rectum 
are  very  soothing,  and  operate  favorably  as  a  laxative.  When 
these  are  inapplicable,  small  mucilaginous  or  unctuous  enemata 
may  be  useful,  especially  with  the  addition  of  laudanum  or  any 
of  the  various  narcotics.  Occasionally,  anodyne  suppositories 
may  be  introduced,  when  injections  give  pain.  The  free  use  of 
cold  water  internally  is  very  valuable  as  a  constant  resort,  while 
the  warm  applications  afford  more  temporary  relief  to  the  pain. 

Nevertheless,  much  cannot  be  accomplished  without  a  careful 
investigation  as  to  the  sources  of  mischief.  This  requires  much 
attention ;  but  whether  it  be  inflammation,  vermes,  hgemorrhoids, 
etc.,  the  cause  must  be  removed.  Our  experience,  however,  leads 
us  to  believe,  that  very  universally  the  cause  is  exterior  to  the 
rectum,  and  dependent  on  some  unnatural  pressure  on  this  tube 
from  enlarged  ovaries  or  other  pelvic  tumors,  or  more  frequently 
from  a  prolapsed  or  retroverted  uterus.  By  rectifying  such  dis- 
placements by  pessaries  and  other  suitable  measures,  the  most 
gratifying  results  have  been  obtained.  Patients  whose  cases  had 
been  deemed  incurable,  and  whose  agonies  had  been  horrible  for 
years,  even  under  the  care  of  experienced  and  educated  men,  have 
thus  been  fully  and  completely  relieved.  Astringent  and  anodyne 
lotions  are  important  as  adjuvants,  especially  when  congestions 


302  TREATMENT    OF    COMPLICATIONS. 

and  discharges  from  the  mucous  membrane  continue.  Hcemor- 
rhoids,  should  any  exist  after  the  rectal  irritation  is  removed, 
may  occasionally  require  the  usual  attention.  All  such  cases 
must  be  carefully  examined  locally,  lest  the  false  notions  of  the 
patient  be  carelessly  sanctioned  by  the  physician.  If  there  be 
really  no  local  irritant  operative,  no  fissures  of  the  anus,  no  pres- 
sure from  displacements,  etc.  etc.,  and  it  be  a  pure  case  of  irrita- 
ble rectum.  Dr.  Meigs  and  others  have  recommended  the  use  of 
metallic  bougies,  which  gradually  distend  the  spasmodic  rectum, 
and,  at  the  same  time,  blunt  its  sensibility. 


IRRITABLE  VULVA  AND  VAGIXA  (VAGINISMUS). 

The  treatment  of  irritahle  vulva  and  vagina  must  be  founded  on 
the  great  principles  so  frequently  enunciated.  The  symptoms  are, 
however,  so  distressing  in  many  instances  as  to  demand  instant 
attention,  and  perhaps  sometimes  stimulate  the  practitioner  to  an 
heroic  treatment  eventually  mischievous. 

As  occasionally  the  result  of  inflammatory  action^  and  frequently 
complicated  with  an  erythematic  inflammation  of  the  vulva  and 
vagina,  the  acute  and  sometimes  even  the  chronic  cases  call  fdr 
evacuating  remedies.  Hence,  not  only  should  the  patient  be  placed 
at  rest  upon  a  couch  or  hard  bed,  but  saline  laxatives,  refrigerants, 
and  diaphoretics,  should  be  given.  Occasionally  leeches  are  not 
to  be  neglected;  they  should  be  applied,  not  directly  to  the  mem- 
branes interested,  but  to  the  hypogastrium,  thighs,  etc.,  as  revul- 
sives. These  may  be  assisted  by  the  relaxing  influences  of 
general  and  local  warm  baths,  fomentations,  and  warm  mucilagi- 
nous injections  to  the  vagina,  all  of  which  favor  relaxation  and 
resolution.  Cold  ablutions  and  injections  do  not  prove  useful, 
as  the  reaction  is  often  so  great  as  to  aggravate  the  symptoms. 
When  the  inflammation  has  diminished,  preparations  of  opium 
and  other  anodynes,  solutions  of  borax,  nitrate  of  silver  and 
iodine  will  often  afford  great  relief  as  local  applications. 

In  chronic  cases  of  irritable  vulva  and  vagina  the  causes  must 
be  carefully  investigated  and  removed,  not  only  inflammation  as 
above  alluded  to,  but  simple  irritation  from  the  states  of  the  blad- 
der, uterus,  and  rectum — such  as  ha3morrhoids,  acrid  discharges 
from  the  vagina  and  uterus,  displacements  of  the  uterus,  ascarides, 


IRRITABLE    VULVA    AND    VAGINA.  803 

pessaries  of  improper  materials,  or  too  large,  or  foul  from  reten- 
tion of  the  secretions. 

Whatever  may  be  the  source  of  mischief,  it  must  be  carefully 
and  perseveringly  attended  to.  Every  practitioner  must  speak 
from  his  own  experience  as  to  the  frequency  of  any  particular 
cause.  We  however  would  state,  that  in  a  very  large  majority 
of  cases,  irritable  vulva  and  vagina  is  maintained  by  an  irritable 
and  displaced  uterus ;  and  hence  the  most  successful  practice  is 
to  persevere  slowly  and  judiciously  in  rectifying  the  displaced 
organ  by  means  of  pessaries,  of  proper  material  and  form,  scienti- 
fically adjusted.  They  operate  mainly  by  removing  the  cause  of 
irritation,  of  congestion,  etc.;  but  they  have,  when  properly 
managed,  another  influence  which  perhaps  many  would  not  have 
suspected.  They  have  a  decided  tendency  to  diminish  and  obtund 
the  vaginal  sensibilities.  The  more  they  are  employed,  the  more 
tbey  are  tolerated.  Each  successive  vaginal  operation  is  made 
with  less  pain  and  discomfort  than  the  preceding.  This  is  noticed 
by  the  patient  as  well  as  by  the  physician.  This  practice  is  in 
unison  with  the  employment  of  bougies  to  the  urethra  and  rectum. 
Hence,  Churchill,  Sims,  Meigs,  and  others  have  employed  gum- 
elastic,  metallic,  or  glass  bougies  of  different  sizes,  to  be  used 
daily,  and  with  the  effect  of  diminishing  sensibility,  contractions, 
and  spasms  of  the  vagina.  They  are  supposed  to  be  more  efficient 
when  covered  with  anodyne  ointments.  In  our  experience,  pes- 
saries are  far  less  troublesome,  and  entirely  free  from  the  moral 
objections  which  have  been  justly  urged  against  the  use  of  the 
bougie. 

In  obstinate  cases  of  mere  irritability,  other  remedial  agents 
are  valuable ;  not  only  warm  applications,  poultices,  etc.,  as 
temporary  means,  but,  as  more  permanently  usefvil,  tepid,  cool, 
and  eventually  cold  washes,  local  and  general  baths,  tepid  and 
cool  vaginal  injections,  if  they  do  not  produce  pain,  of  injections 
of  cold  water  to  the  rectum  ;  also  mucilaginous  and  oily  injections 
to  the  vagina  as  well  as  to  the  vulva,  the  free  local  application  of 
glycerin,  laudanum,  morphia,  camphor,  aconite,  and  other  ano- 
dynes. The  use  of  the  carbonic  acid  gas,  and  also  of  chloroform, 
in  these  and  analogous  cases,  has  been  proposed,  and,  it  is  said, 
employed  advantageously.  In  these  chronic  cases  more  stimu- 
lating applications  are  sometimes  useful,  as  vinegar,  alcohol, 
brandy,  spirits  of  camphor,  and  even  diluted  spirits  of  ammonia. 


804  TREATMENT    OF    C  0  MPLI  C  ATI  OXS. 

When  very  obstinate,  the  folloAving  articles  are  perhaps  more 
generally  useful  than  any  others,  namely,  the  tincture  and  other 
preparations  of  iodine,  and  also  the  nitrate  of  silver.  The  former 
especially,  more  or  less  diluted,  will  often  relieve  the  burning 
and  itching  when  other  means  have  failed ;  sometimes  the  relief 
is  but  temporary,  requiring  the  constant  recurrence  to  the  wash ; 
in  others,  its  influence  is  more  permanent.  The  strong  recom- 
mendations and  the  alleged  necessity  of  constant  resort  to  the 
nitrate  of  silver,  must  be  received  "cum  grano  salis;"  neverthe- 
less this  preparation  is  often  useful.  The  best  form  in  which  to 
apply  it,  is  the  solution,  as  a  wash  to  the  vulva  by  means  of  a 
delicate  brush,  or  mop,  or  by  the  syringe  to  the  vagina.  In  ob- 
stinate cases,  the  solid  caustic  has  been  advised,  and  we  have  applied 
it  to  the  whole  circumference  of  the  orifice  of  the  vagina,  causing 
temporary  pain,  sometimes  severe,  but  also  a  subsequent  diminu- 
tion of  suffering ;  yet  this  was  seldom  so  marked  as  to  induce  a 
frequent  return  to  its  employment. 

More,  however,  can  be  said  in  favor  of  the  nitrate  of  silver, 
when  applied  to  the  irritable  •painful  condition  of  the  orifice  of  the 
urethra^  especially  when  turgid  and  hj^pertrophied,  as  if  a  tumor 
actually  existed.  In  these  cases,  occasionally,  we  have  seen  the 
caustic  do  great  service  ;  but  here  also  patient  and  physician  will 
often  experience  great  disappointments.  Mr.  Burns,  of  Glasgow, 
has,  in  these  neuralgic  conditions  of  the  vulva,  which  have  defied 
ordinary  treatment,  recommended  the  division  of  the  pudic  nerve, 
making  a  free  incision  through  the  walls  of  the  vagina.  Messrs. 
Debout  and  Michon  have  also  adopted  the  same  plan.  Professor 
Simpson,  however,  advises  a  division  of  the  nerve  by  means  of 
the  tenotomy  knife ;  and  Dr.  Marion  Sims  makes  two  incisions, 
one  on  either  side  of  the  posterior  margin  of  the  orifice  of  the 
vagina,  converging  towards  the  middle  line,  so  as  to  include  a 
wedge  like  portion  of  the  perineum.  The  author,  however,  has 
met  with  no  case  in  which  the  knife  would  seem  to  be  justifiable. 


IRRITABLE  BLADDER  AND  URETHRA. 

The  treatment  of  irritable  bladder  and  urethra  will  often  be 
prominently  brought  to  the  attention  of  the  practitioner  by  the 
unceasing  complaints  of  the  poor  sufferers. 


IRRITABLE    BLADDER    AND    URETHRA.  805 

Days  and  years  may  elapse  with  but  slight  mitigation  of  the 
torment ;  until  the  source  of  irritation  be  discovered  and  removed. 

Removal  of  the  Cause. — The  bladder  should  be  carefully  exa- 
mined, to  ascertain  whether  there  be  any  gravel,  calculus,  or 
foreign  matters  present ;  whether  there  be  thickening  or  indura- 
tion of  the  coats  of  this  viscus  or  of  the  urethra ;  and  whether  there 
be  any  natural  or  preternatural  contractions  or  strictures  of  the 
urethra.  Special  attention  should  be  paid  to  the  cystic  excre- 
tions ;  to  the  presence  or  absence,  as  well  as  the  character,  of  de- 
posits from  the  urine — so  as  to  determine  how  far  the  character 
of  the  kidney  or  cystic  secretions  are  involved  in  the  causation, 
and  if  there  be  any  nephritis,  cystitis,  or  urethritis  present.  So 
also  we  must  examine  the  condition  of  the  orifices  of  the  urethra 
and  of  the  vagina,  the  state  of  the  vagina,  of  the  uterus,  of  the 
ovaries,  of  the  anus,  and  of  the  rectum.  Investigations  as  to  every 
source  of  irritation,  whether  one  or  many,  must  be  sedulously  and 
perseveringly  made,  if  there  be  any  expectation  of  imparting  per- 
manent relief. 

As  formerly  intimated,  by  far  the  most  frequent  cause  of  irrita- 
ble bladder  is  the  dragging  or  pressure  on  this  viscus  or  its  neck  by 
the  uterus,  when  displaced,  hypertrophied,  or  otherwise  enlarged. 
In  all  such  instances  relief  will  be  afforded  just  in  proportion  as 
this  source  of  irritation  is  removed.  If  the  displacement  can  be 
speedily  obviated,  the  terrible  sensations  of  cystic  irritation  dis- 
appear as  if  by  magic ;  but  if  it  be  a  slow  and  difficult  process, 
the  dysuria  will  be  moderated,  but  will  be  more  or  less  persistent 
until  the  displacement  be  removed.  The  supporters,  however, 
Avhich  are  to  accomplish  this  desirable  object,  must  be  so  arranged 
as  not  themselves  to  press  upon  or  irritate  the  urethra  or  the 
bladder.  This  is  often  a  serious  dif&culty ;  but,  nevertheless,  it 
does  not  invalidate  the  principle  that  the  cystic  irritation  depends 
on  such  displacements,  and  is  to  be  relieved  by  their  removal. 
All  other  principles  and  modes  of  treatment,  even  when  perse- 
vered in  for  months  and  years,  by  anxious,  judicious,  and  expe- 
rienced practitioners,  have  so  often  failed;  and,  in  these  very 
cases,  relief  has  been  afforded  so  quickly,  effectually,  and  perma- 
nently by  the  judicious  and  scientific  use  of  a  pessary,  that  its 
employment  must  be  urged  in  all  chronic  cases  of  irritable 
bladder  connected  with  an  enlarged  or  displaced  uterus.  Indeed, 
under  the  most  desperate  circumstances,  complete  relief  will 
20 


306  TREATMENT    OF    COMPLICATIONS. 

often  follow  its  adjustment.     Many  cases  by  way  of  illustration 
might  be  mentioned ;  one  may  suffice. 

Case. — A  gentleman,  some  time  since,  described  to  us  tbe  case 
of  his  wife.  She  was  about  thirty-five  years  of  age,  and  had  been 
tormented  with  dysuria  for  many  months,  which  was  accompanied 
with  so  much  straining  that  blood  occasionally  was  discharged. 
Some  general  directions  were  given  at  the  time,  and  afterwards  a 
long  correspondence  as  to  internal  and  external  remedies,  was 
conducted  with  the  attendant  physician,  but  to  no  permanent 
advantage.  On  her  subsequent  visit  to  Philadelphia,  an  enlarged 
and  completely  retroverted  uterus  was  discovered,  producing 
more  or  less  leucorrhoea  and  menorrhagia.  Tonics  internally, 
astringent  and  cooling  washes  to  the  vagina,  with  the  rectifica- 
tion of  the  uterus  by  a  pessary,  afforded  complete  relief  to  the 
dysuria,  congestion,  and  increased  discharges ;  at  the  same  time, 
her  sensations  of  languor,  pain,  and  weakness  were  so  far  re- 
moved, that  exercise,  before  almost  impossible,  could  be  taken 
with  impunity  and  advantage.  She  soon  returned  home,  per- 
fectly well. 

In  most  cases  time  is  required ;  and  when  great  delay  is  expe- 
rienced, it  is  due,  not  to  any  want  of  correctness  in  the  principle, 
but  simply  to  mechanical  difficulties  preventing  the  complete 
restoration  of  the  uterus  to  its  natural  position  in  the  pelvis. 

Palliative  remedies. — Fomentations,  poultices,  warm  hip-baths, 
warm  mucilaginous  vaginal  and  rectal  injections,  with  or  without 
the  addition  of  anodynes  and  antispasmodics  ;  the  use  of  laudanum 
and  other  analogous  washes  or  ointments  to  the  orifices  of  the 
bladder  and  vagina,  may  all  be  resorted  to  with  more  or  less 
advantage. 

Various  injections  to  the  urethra  and  bladder  are  useful.  So- 
lutions of  morphia  and  other  narcotics  have  been  employed,  and 
often  with  advantage.  Weak  solutions  of  the  nitrate  of  silver 
are  particularly  demanded,  when  there  are  any  indications  of 
inflammatory  action  present. 

Bougies  and  sounds  are  very  valuable  whenever  any  strictures, 
or  obstructions  exist  in  the  urethra ;  they  have  also  been  much 
used  on  the  principle  of  diminishing  irritability  of  mucous  mem- 
branes by  gentle  but  repeated  mechanical  attrition.  The  fact, 
already  alluded  to,  that  the  sound  passed  into  the  male  urethra 
blunts  its  sensibility,  has  led  to   the  same   experiment   on  the 


MORBID    STATES    OF    THE    OVARIES.  307 

female  with  much  success  ;  and  this  probably  would  be  still  more 
universal  if  the  original  and  aggravating  causes  were  always 
first  completely  removed. 

Besides  the  applications  above  enumerated,  occasionally  more 
powerful  injections  have  been  employed,  as  strong  solutions  of 
the  nitrate  of  silver,  the  diluted  spirits  of  camphor,  aqua  ammo- 
nise,  spirits  of  turpentine,  and  also  preparations  of  iodine.  They 
are,  however,  all  of  imcertain  value,  and  are  liable  to  serious 
objections. 

Something  may  be  expected  from  drinks  and  internal  medi- 
cines even  in  cases  of  pure  irritability  of  the  bladder,  by  increas- 
ing the  quantity  and  altering  the  character  of  the  urine.  Those 
are  to  be  preferred  which  render  it  less  saline,  and  of  course  less 
stimulating  to  the. sensitive  tissues  of  the  bladder  and  the  urethra. 
Thus  the  free  use  of  mucilaginous  fluids,  and  of  mild  diuretics, 
is  very  useful.  The  carbonates  of  soda  and  potash,  the  sweet 
spirits  of  nitre,  the  buchu,  the  uva  ursi,  the  taraxacum,  and  espe- 
cially the  balsam  copaiva,  are  excellent.  Laxatives,  particularly 
the  antacid  and  the  oleaginous  articles,  have  a  similar  effect,  and 
also  act  beneficially  by  removing  various  sources  of  irritation 
from  the  stomach  and  bowels.  Nevertheless,  in  protracted,  pain- 
ful cases,  the  chief  dependence  of  the  physician  must  be  on  the 
preparations  of  opium,  per  vaginam,  urethram,  seu  rectum,  until 
the  cause  can  be  detected  and  removed. 


MORBID  STATES  OF  THE  OYARIES. 

Attention  has  already  been  fixed  on  the  difficulty  of  diagnosis 
in  all  cases  of  inflammatory  and  other  morbid  states  of  the  ovaries, 
where  there  is  not  much  enlargement  of  these  organs.  In  the 
treatment,  however,  of  acute  ovaritis,  fortunately  this  fact  is  of 
minor  importance ;  as,  whether  it  be  the  ovary  or  other  append- 
age of  the  uterus,  or  the  uterus  itself,  positive  inflammatory  symp- 
toms demand  rest,  leeches,  and  other  antiphlogistic  measures.  The 
caution,  however,  was  given,  not  to  pursue  this  practice  in  chronic 
cases,  under  the  idea  of  a  pain  in  the  region  of  the  ovary,  being 
indicative  of  ovaritis ;  especially  in  those  numerous  cases  where 
no  fever  is  present  For,  judging  from  our  experience  in  the 
treatment  of  such  cases,  it  would  seem  that  this  pain  is  generally 


808  TREATMENT    OF    COMPLICATIONS, 

dependent  on  uterine  displacements,  wliicTi  either  directly  or  indi- 
rectly through  the  medium  of  the  ligamenta  rotunda,  very  uni- 
versally excite  pain  in  the  right  or  left  side  above  the  groins. 
Such  cases  we  have  known  treated  for  a  long  time  for  inflamma- 
tion of  the  ovaries  without  advantage,  and  afterwards  completely 
relieved  by  removing  the  uterine  trouble. 

Tumors  of  the  ovaries^  when  still  in  the  cavity  of  the  pelvis, 
often  irritate  the  uterus  or  the  sacral,  obturator,  or  other  nerves 
of  the  pelvis,  by  their  weight  and  pressure,  and  thus  excite  all 
the  symptoms  of  an  irritable  and  displaced  uterus.  Sometimes 
they  themselves  become  irritable  and  sensitive.  They  are,  there- 
fore, to  be  treated  on  similar  principles.  The  pressure  on  the 
uterus  and  the  floor  of  the  pelvis  is  to  be  counteracted  by  mecha- 
nical measures  per  vaginam,  so  arranged  that  while  this  result 
is  obtained,  no  irritation  shall  be  produced.  Perfect  relief  may 
be  expected  on  this  principle ;  while  to  treat  such  tumors  as  iDflam- 
matory,  or  to  attempt  their  "discussion"  by  evacuants,  counter- 
irritants,  and  alteratives  of  any  character,  would  be  useless  and 
positively  injurious  on  account  of  the  confinement,  to  which  the 
patient  must  be  subjected,  the  loss  of  strength  and  consequent 
aggravation  of  her  wretched,  painful,  and  nervous  affections. 
The  patient  should  be  strengthened  by  tonics,  fresh  air,  good 
diet,  and  exercise,  as  in  other  irritable  complaints. 

If  the  tumors  of  the  ovaries  be  large,  so  as  to  rise  into  the 
cavity  of  the  abdomen,  they  are  generally  innoxious,  for  then, 
like  the  uterus  after  the  fourth  month  of  gestation,  they  are  sup- 
ported by  the  brim  of  the  pelvis ;  so  that  no  pressure  is  made  on 
the  delicate  organs  and  nerves  of  the  pelvis,  and  the  tumors 
themselves  are  found  seldom  inflamed  or  sensitive. 

In  such  cases  it  has  been  our  practice  for  very  man}'-  years,  and 
there  has  been  no  cause  for  regret,  to  attend  to  the  general  health 
and  strength  of  the  patient,  and  to  abandon  all  local  treatment. 
If  possible,  let  the  patient  forget  the  existence  of  the  tumors,  and 
she  will  usually  enjoy  that  portion  of  health  and  activity  which 
belongs  to  her  age  and  sex. 

The  attempts  to  resolve  such  tumors,  experience  proves  to  be 
vain ;  and  to  extirpate  them  by  the  operation  of  gastrotomy  is 
greatly  to  endanger  life,  for  a  disease  which  very  rarely  termi- 
nates fatally,  and  even  then  from  accidental  complications,  which 


IRRITATION"    OF    THE    PELVIC    NERVES.  309 

of  course  do  not  invalidate  tlie  general  principle  or  tlie  practical 
deduction. 


IRRITABLE  LYMPHATIC  GLANDS. 

The  same  principles  are  to  be  tlae  guide  of  the  practitioner  in 
regard  to  those  small  irritable  tumors,  jjrohahly  of  the  lymphatic 
glands  which  occasionally  complicate  irritable  uterus.  Much  at- 
tention and  perseverance  will  be  required,  in  order  at  once  to 
relieve  any  uterine  displacement  which  may  exist,  and  also  to 
prevent  pressure  from  or  against  these  irritable  tumors.  Such 
cases,  as  those  already  referred  to,  will  thus  be  successfully  man- 
aged. 


IRRITATIOX  OF  THE  PELVIC  NERVES. 

After  the  observations  which  have  been  made,  the  treatment  of 
all  those,  often  terrible,  sufferings  arising  from  irritations  of  the 
pelvic  nerves,  is  apparent.  Eemove,  if  practicable,  the  cause  of 
irritation,  whether  pressure  of  the  uterus,  the  ovaries,  lymphatic 
or  other  tumors  of  the  pelvis,  collections  of  feculent  matters  in 
the  rectum,  or  pessaries  or  other  foreign  substances  in  the  vagina, 
etc.  Very  generally  this  important  object  can  be  readily  accom- 
plished, to  the  indescribable  relief  of  the  patient.  In  some,  unfor- 
tunately, even  when  purely  neuralgic,  the  source  of  mischief 
cannot  be  detected,  or  if  detected  cannot  be  relieved.  Generally 
such  cases  continue  for  years,  and  may  probably  gradually  disap- 
pear under  the  revolutions  of  the  animal  economy ;  but  art  can 
afford  no  radical  relief.  Palliatives  are  the  only  remedies  we  can 
present  to  the  disappointed  sufferer. 

Cases. — Two  such  individuals  we  are  now  watching  over  with 
painful  interest ;  both  of  them  are  bedridden,  one  for  some  fifteen 
years,  another  for  twenty-five  years.  In  neither  case  is  there  any 
evidence  of  febrile  excitement,  and  the  general  health  is  as  good 
as  is  consistent  with  the  confinement,  loss  of  appetite  and  of 
sleep,  with  pain  and  nervous  distress  radiating  from  one  organ 
to  another. 

Occasionally  these  said  irritable  states  of  the  pelvic  nerves  are 


310  TREATMENT    OF    COMPLICATIONS. 

purely  symptomatic  of  inflammatory  or  malignant  diseases,  and 
also  of  morbid  growths,  involving  one  or  more  of  the  soft  or  bony 
tissues  of  the  pelvis.  They  are  among  the  terrible  sequelae  of 
scirrhus  and  cancer  of  the  bladder,  vagina,  uterus,  and  rectum;  of 
tumors  immovably  connected  with  the  parietes  of  the  pelvis ;  of 
alterations  in  the  neurilemma,  or  in  the  substance  of  the  nerves; 
of  diseases  of  the  bony  canals  of  the  sacrum,  or  of  the  sacrum 
itself. 

Case. — In  one  case  of  horrible  suffering,  Avhich  eventuated  in 
death,  there  was  a  falling  in  of  the  whole  anterior  surface  of  the 
sacrum,  from  the  promontory  downwards.  This  caries  of  the 
sacrum  was  unaccompanied  by  any  apparent  external  deformity, 
and  was  only  detected  upon  the  post-mortem  examination. 

All  such  cases,  however,  do  not  strictly  come  under  the  name 
of  "irritable  diseases."  The  neuralgia  may  be  terrible,  but  it  is  to 
be  relieved  by  removing  the  primary  disease,  whether  inflamma- 
tory or  organic.  It  is  purely  symptomatic.  Precisely  as  a  dis- 
eased tooth  may  produce  neuralgia  of  the  face,  or  a  neuritis  may 
excite  neuralgia  and  spasms  of  branches  of  the  a,flfected  nerve;  so 
inflammatory  or  other  diseases  of  the  pelvic  viscera  may  have 
neuralgic  symptoms,  which  are  to  be  relieved,  in  all  such  cases, 
by  antiphlogistic,  rather  than  by  nervine  remedies. 


GENERAL  REMARKS. 

The  prognosis,  as  formerly  intimated,  of  pure  irritable  diseases 
is  favorable.  Death  very  seldom  results ;  nevertheless  years  are 
often  passed  in  great  suffering;  but  still,  the  hope  may  always  be 
held  out  to  the  patients,  that  as  the  sensibilities  and  functions  of 
the  economy  alter  in  the  progress  of  life,  a  recovery  may  be  an- 
ticipated. Hence,  as  the  peculiar  excitements  of  the  ovaries  and 
uterus  disappear  towards  the  fiftieth  year,  nervous  and  hysterical 
diseases  often  vanish,  or  at  least  diminish  in  intensity. 

No  organic  changes  are  necessarily  connected  Math  irritable 
uterus,  unless  "hypertrophy"  be  embraced  by  that  term.     The. 
congestions,  which    so    frequentl}'-  ensue,  are    generally  sponta- 
neously relieved  by  the  leucorrhoeal  and  menorrhagic  discharges  ; 
but  this  is  sometimes  only  a  partial  relief,  so  that  congestion  is 


GENERAL    REMARKS.  '  311 

followed  by  an  unusual  development  of  the  organ  without  appa- 
rent alteration  of  tissue. 

The  treatment  of  this  hypertrophy  is  mainly  on  the  grand 
principle,  here  so  constantly  inculcated,  namely,  the  removal  of 
the  original  cause  of  the  irritable  organ ;  the  congestion  disap- 
pears, followed  by  the  cessation  of  leucorrhoea  and  monorrhagia, 
and  more  slowly  of  the  hypertrophy.  It  is  precisely  analogous 
to  the  pregnant  uterus;  which  is  developed  by  the  irritation  and 
congestion  excited  by  the  foetus,  and  gradually  but  surely  returns 
to  its  pristine  state  after  the  child  is  delivered.  Hence,  as  pes- 
saries remove  the  causes,  they  are  the  best  remedies  for  au  en- 
larged irritable  uterus,  and  by  their  employment  the  displacement, 
pain,  congestion,  and  the  consequent  development  may  be  re- 
lieved. In  such  cases,  they  must  be  worn  for  a  long  time,  as  the 
uterus  is  heavy,  and  increased  in  size;  which  predisposes  to  a  con- 
tinuance or  return  of  the  local  troubles.  They  may  be  assisted, 
perhaps,  by  the  use  of  anodyne  suppositories  or  washes  to  the 
vagina,  by  cool  or  cold  ablutions  internally  to  the  uterus,  and  ex- 
ternally to  the  surface  of  the  body,  and  perhaps,  also,  by  the  use 
of  iodine  and  nitrate  of  silver  to  the  uterus.  No  evacuants  should 
be  resorted  to,  but  everything  be  employed  to  give  tone  to  the 
general  system,  and  increase  the  "  vis  medicatrix  naturae." 

In  some  few  cases  of  protracted  suffering  from  irritable  diseases, 
especially  when  improperly  managed,  or  absolutely  neglected,  it 
has  been  mentioned  that  secondary  complaints  of  a  dangerous 
character  may  ensue.  The  powers  of  the  patient  may  be  greatly 
depressed  by  the  want  of  air  and  of  exercise,  by  the  vaginal  dis- 
charges, the  pain  and  nervous  distress,  the  nausea,  the  vomiting, 
and  other  dyspeptic  symptoms.  In  all  such,  the  patient  may 
rapidly  succumb  under  an  attack  of  any  acute  disease. 

In  other  instances,  as  intimated,  there  is  not  only  a  failure  of 
strength  and  an  increase  of  irritability,  but  such  a  deterioration 
of  the  blood  and  the  various  secretions,  that  death  may  possibly 
result  from  pure  inanition,  or  be  accelerated  by  erythematic  or 
other  inflammatory  irritations  of  the  mucous  membranes,  or  the 
development,  it  may  be,  of  tuberculous  diseases.  Nevertheless, 
we  must  not  despair  of  such  cases,  if  organic  disease  be  absent. 
Indeed,  much  may  be  expected  by  a  protracted,  patient  perse- 
verance in  a  well  directed  treatment.  Let  the  original  uterine 
irritation  be  relieved,  and  much  is  already  accomplished.     The 


312  TREATMENT    OF    COMPLICATIONS. 

stomach  will  be  more  retentive,  and  the  disgust  for  food  dimi- 
nished or  removed.  Simple  but  nutritious  articles  of  diet  may 
be  given ;  digestion  may  be  assisted  by  tonics,  condiments,  and, 
perhaps,  by  other  stimuli.  Every  variety  of  palliatives  for  dis- 
tressing and  urgent  symptoms,  should  be  suitably  employed  "pro 
re  nata."  The  patient  may  be  borne  into  the  open  air,  and  exer- 
cise by  gestation  be  very  early  resorted  to,  assisted  by  careful 
attention  to  the  whole  cutaneous  surface,  by  means  of  frictions, 
liniments,  and  ablutions  of  various  kinds.  Let  the  mind  and  the 
heart,  as  well  as  the  body  be  addressed,  and  great  things  may  be 
anticipated.  The  digestive  powers  improving,  better  chyle  and 
blood  will  be  elaborated ;  and  of  course  more  healthy  secretions, 
greater  strength,  and  a  diminution  of  irritability,  of  mental,  moral, 
and  physical  suffering  will  result,  until  the  whole  economy  will 
become  completely  resuscitated.  A  new  lease  of  life,  with  the 
usual  enjoyments  pertaining  to  humanity,  will  be  granted  to  the 
patient  who  was  so  lately  in  despair.  That  such  results  cannot 
always  be  expected  in  these  unfortunate  patients,  should  be  to 
the  practitioner  but  an  additional  stimulus  to  exert  his  best  powers 
and  his  most  untiring  efforts  to  succeed,  if  possible,  or  at  least  to 
have  the  melancholy  happiness  of  comforting  and  sustaining  the 
moral  and  physical  energies  of  his  interesting  patient. 


PART  II. 

DISPLACEMENTS   OF   THE    UTERUS. 


CHAPTER    I. 

NATURAL    POSITION   AND    SUPPORTS  OF   THE    UTERUS. 

From  the  foregoing  analysis  of  nervous  diseases  in  women,  it 
would  appear  that  irritable  uterus  is  most  frequently  their 
^'■proximate  caused  It  is,  indeed,  the  "  ^2^5e  morhusJ''  When  it  is 
present,  there  may  ensue  distress,  neuralgia,  spasms,  congestion, 
leucorrhoea,  monorrhagia,  dysmenorrhoea,  irritations  of  the  blad- 
der, of  the  rectum,  of  the  sacral  and  other  nerves,  of  the  spinal 
marrow,  and  of  the  brain,  with  a  corresponding  disturbance  of 
functions,  and  of  the  extensive  reflex  and  sympathetic  influences 
in  almost  every  part  of  the  economy.  Whence,  then,  arises  the 
irritable  condition  of  this  important  organ,  which  plays  such  a 
I  role  in  the  female  system  ?  The  various  predisposing  and  ex- 
citing causes  have  already  been  fully  detailed.  Of  these,  dis- 
placement of  the  uterus  was  mentioned  as  one  of  the  most 
frequent  and  persistent,  as  being  often  the  sole  origin  of  the 
complaint,  and,  very  frequently,  maintaining  the  disease  in  oppo- 
sition to  the  best  remedial  efforts.  Most  of  these  enumerated 
causes  are  so  well  understood,  as,  perhaps,  to  need  no  special 
elucidation ;  but  displacements  of  the  uterus  have  been,  and  still 
are,  the  subject  of  every  variety  of  opinion  in  the  profession. 
They  are  completely  ignored  by  very  many,  and  by  them  con- 
sidered as  of  no  consequence ;  while,  by  perhaps  most  of  the 
modern  pathologists,  they  are  regarded  as  secondary,  not  pri- 
mary— as  consequential,  not  causative — and  hence,  as  demanding 
no  special  treatment,  but  disappearing  as  their  supposed  cause  is 
removed. 


3ii      NATURAL    POSITION    AND    SUPPORTS    OF    UTERUS. 

A  very  large  majority  of  practitioners,  not  having  their  minds 
directed  to  this  subject,  have  very  indefinite  ideas  as  to  the 
character  or  the  treatment  of  malpositions  of  the  uterus ;  and 
even  among  those  who  recognize,  to  a  greater  or  less  degree, 
their  importance  in  a  therapeutical  point  of  view,  there  is  great 
discrepancy  of  opinion  upon  numerous  anatomical  and  patholo- 
gical questions  connected  with  them.  The  proper  modes  of  relief, 
whether  by  medicinal  or  mechanical  means,  and,  if  by  the  latter, 
whether  external  or  internal  supporters,  of  what  material,  form, 
size,  etc.,  have  all  afforded  fruitful  subjects  for  debate.  Indeed, 
may  it  not  be  said  that  the  principles  involved  in  cases  of  dis- 
placed uterus,  whether  pathological  or  practical,  have  not  yet 
been  established  to  the  satisfaction  of  the  professional  mind  ? 

To  complete,  therefore,  the  analysis  of  the  nature  and  treatment 
of  irritable  uterus,  as  thus  far  detailed,  the  causes,  effects,  and 
treatment  of  malpositions  of  this  organ  must  be  presented.  If 
these  be  not  understood,  and  if  the  principles  resulting  therefrom 
be  not  the  guide  of  the  practitioner,  comparatively  little  good 
can  result  from  the  whole  of  this  investigation.  Having  a  firm 
faith  in  the  truth  of  the  principles  and  the  success  of  the  practice, 
the  author  offers  his  views,  for  examination  by  his  medical 
brethren. 


NATURAL  POSITION  OF  THE  UTERUS. 

To  understand  this  subject,  some  preliminary  anatomical  and 
physiological  facts  must  be  pointed  out. 

The  Cavity  of  the  Pelvis. — The  composition,  form,  and 
position  of  the  pelvis,  as  also  its  coverings  and  its  linings,  are  of 
course  known  to  all.  The  cavity  of  the  inferior  pelvis,  with  its 
fasciae  and  muscles  so  arranged  as  to  present  a  uniformly  concave 
surface  without  diminishing  its  diameters,  should  be  carefully 
studied;  and  the  arrangement  of  the  levatores  ani  muscles,  which 
form  the  whole  floor  and  much  of  the  lateral  portions  of  the 
pelvis,  should  always  be  borne  in  mind. 

Pelvic  Nerves. — It  is  also  all-important,  as  will  be  hereafter 
seen,  for  the  practitioner  to  notice  the  size  and  location  of  the 
pelvic  nerves;  especially  of  the  anterior  crural  nerve  from  the 


THE    CAVITY    OF    THE    PELVIS, 


815 


lumbar  plexus,  pursuing  its  course  along  the  margin  of  tlie  supe- 
rior strait  to  the  groin;  of  the  obturator  nerve  from  the  same 
plexus,  descending  near  the  sacro-iliac  symphysis  for  about  an 
inch  below  the  superior  strait,  and  then  coursing  under  the  supe- 
rior margin  of  the  levator  ani  muscle,  to  make  its  exit  through 
"the  obturator  foramen  to  the  inner  muscles  of  the  thigh;  of  the 
three  or  four  superior  sacral  nerves,  on  either  side,  coming  out 


SYMPATHETIC   NERVE 

iiiyiiiiji,,,! 


PELVIC     NERVES. 


of  the  foramina  on  the  front  of  this  bone,  and  pursuing  a  lateral 
course  in  grooves  to  the  great  ischiatic  foramen,  to  form  the 
sacro-sciatic  plexus,  the  largest  in  the  body ;  and  of  the  inferior 
sacral  nerves,  also  from  foramina  on  the  anterior  surface  of  the 
sacrum,  and  distributed  to  the  important  tissues  in  the  coccygeal 
region.     Attention  should  also  be  fixed  upon  the  lower  portions 


316      NATURAL    POSITION    AND    SUPPORTS    OF    UTERUS. 

of  the  sympatlietic  nerve,  witli  its  lumbar  aod  sacral 'ganglia,  and 
their  free  communications  with  the  cerebro-spinal  nerves. 

The  Uterus. — In  the  midst  of  the  pelvic  cavity  is  placed  the 
uterus,  a  flattened  cone,  measuring  from  two  and  a  half  to  three 
inches  in  length,  about  one  and  a  half  transversely  at  its  base  or 
fundus,  and  one  inch  from  the  anterior  to  the  posterior  surface. 


AXES    OF    THE   BODY    AND    PELVIS. 


Situation  and  Direction. — It  is  situated  between  the  pubis  and 
sacrum,  with  the  urinary  bladder  in  front,  and  the  rectum  behind 
and  underneath.  By  areolar  and  other  tissues,  the  cervix  and 
a  small  portion  of  the  body  of  the  uterus  are  closely  adherent 
anteriorly  to  the  bladder,  so  that  the  motions  or  position  of  one 
organ  must  influence  that  of  the  other. 

The  longitudinal  axis  of  the  uterus,  passing  from  the  centre  of 
the  fundus  to  the  os  uteri,  may  be  said  to  correspond  to  the  direc- 
tion of  the  axis  of  the  superior  strait  of  the  pelvis ;  id  est,  to  a  line 
drawn  perpendicular  to  the  plane  of  that  strait,  which,  if  extended, 
will  strike  inferiorly  the  os  coccygis,  and  superiorly  the  linea  alba 


SITUATION    AND    DIRECTION    OF    THE    UTERUS.       817 


318      NATURAL    POSITION    AND    SUPPORTS    OF    UTERUS. 

of  the  abdominal  muscles,  some  distance  below  the  umbilicus. 
This  parallelism  of  the  axis  of  the  uterus  with  that  of  the  superior 
strait,  when  the  organ  is  in  situ  naturali^  and  the  necessary  con- 
sequences, should  never  be  forgotten  in  practice.  For,  it  follows 
that  the  os  uteri  points  towards  the  coccyx,  and  the  fundus  to- 
wards the  linea  alba;  also,  that  when  a  woman  is  on  her  back,  the 
uterus  is  not  far  from  being  vertical ;  but  when  she  is  erect,  this 
organ  is  very  oblique,  corresponding  to  the  obliquity  of  the  pel- 
vis, the  fundus  forward,  the  os  uteri  backward,  with  the  anterior 
surface  nearly  parallel  to  the  inner  surface  of  the  body  of  the 
pubis. 

A  necessary  consequence  of  this  obliquity  of  the  uterus  has 
been  strangely  overlooked,  namely,  that  in  vaginal  examinations 
the  finger  or  instrument  does  not  come  in  contact,  at  first,  with 
the  OS  uteri — the  uterus  being  in  its  normal  position — but  with  the 
anterior  part  of  the  neck  and  body  of  the  uterus,  as  covered  below 
by  the  vagina  alone,  or,  high  up,  by  the  vagina  and  bladder.  To 
feel  the  os  tincaB,  the  finger  must  be  passed  deep  into  the  vagina, 
so  as  to  get  under  the  extremity  of  the  neck  of  the  uterus;  for,  the 
OS  does  not  in  any  degree  present  towards  the  orifice  of  the  vagina, 
but  towards  the  posterior  perineum,  the  region  of  the  coccyx. 
This  region  is  the  bottom  of  the  pelvis,  and  directly  opposite  to 
the  superior  strait.  But  the  orifice  of  the  vagina  is  under  the 
arch  of  the  pubis,  on  the  anterior  surface  of  the  pelvis,  and  of 
course  opposite,  not  to  the  superior  strait,  but  to  the  second  bone  of 
the  sacrum.  The  axis  of  the  vagina,  moreover,  is  not  represented 
by  a  straight  line  drawn  from  the  centre  of  its  orifice  to  the  second 
bone  of  the  sacrum,  for  this  tube,  instead  of  passing  iipward  and 
backward,  passes  downward  and  backward,  and  curves  along  the 
perineum  and  rectum.  Again,  its  axis  does  not  correspond  with 
the  axis  of  the  inferior  strait,  for  this,  as  it  strikes  the  first  bone 
of  the  sacrum,  and  inclines  upward  even  more  than  the  line  above 
mentioned  ;  besides,  the  vagina  not  only  is  a  curved  tube,  but 
has  the  centre  of  its  orifice  above  the  centre  of  the  inferior  strait, 
namely,  between  it  and  the  pubis.  These  points  should  be  accu- 
rately observed,  for  the  natural  direction  of  the  axis  of  the  uterus 
and  that  of  the  vagina  should  never  be  forgotten;  and  it  should 
always  be  borne  in  mind  that,  on  account  of  their  relative  direc- 
tions, they  meet  each  other  at  an  acute  angle.  The  bladder  occu- 
pies this  angle  between  the  uterus  and  vagina,  so  that  the  acuteness 


MOBILITY    OF    THE    UTERUS.  819 

of  the  angle  varies,  being  increased  when  the  bladder  is  emptied, 
and  lessened  when  it  is  distended.  It  should  not  be  forgotten  that 
the  vagina  is  a  flattened  tube,  its  anterior  and  posterior  walls 
being  in  contact  with  each  other,  its  greatest  transverse  diameter 
being  towards  its  upper  extremity. 

It  should  also  be  noticed  that  the  uterus,  in  its  normal  posi- 
tion, projects,  anteriorly,  about  one  quarter  of  an  inch  into  the 
vagina,  so  that  the  os  uteri,  its  labia,  and  the  lower  extremity  of 
the  cervix,  are  the  only  portions  of  the  uterus  which  can  possibly 
be  ocularly  examined  by  means  of  specula.  The  rest  of  the  neck 
and  the  whole  body  of  the  uterus  are  above  and  exterior  to  the 
vagina,  floating  among  the  soft  tissues  of  the  intestines  and  blad- 
der. Some  of  the  small  intestines  fall  upon  the  front ;  but  the 
mass  of  them  upon  the  posterior  portions  of  the  organ.  Probably 
in  no  other  location  could  this  viscus  be  so  free  from  injury ;  it  is 
not  in  contact  with  any  solid  or  hard  substance,  but  is  suspended 
in  the  midst  of  tissues,  which,  from  their  construction,  and  their 
pultaceous,  watery,  and  gaseous  contents,  afford  a  secure  nidus, 
not  only  for  a  healthy  uterus,  but  even  for  one  morbidly  sensitive. 

Mobility  of  the  Uterus. — The  uterus  is  a  movable  organ.  It  has 
a  pendulum-like  motion  between  the  pubis  aud  the  sacrum ;  it  is 
pushed  backwards  by  the  distension  of  the  bladder,  and  forwards 
by  the  weight  of  the  intestines,  when  the  bladder  is  empty ;  so 
that  the  axis  of  the  uterus  does  not  always  exactly  coincide  with 
that  of  the  superior  strait.  The  uterus  also  descends  to  a  certain 
extent,  when  any  straining  effort  is  made,  and  is  drawn  up  by  the 
strength  and  elasticity  of  its  attachments. 


SUPPORTS  OF  THE  UTERUS. 

From  its  location  in  the  inferior  part  of  the  body,  the  uterus  is, 
hoAvever,  subjected  to  great  pressure  from  the  weight  of  the  small 
intestines,  the  mesenteric  attachments  of  which  allow  them  to 
sink  around  the  uterus  to  the  lowest  part  of  the  pelvis.  This 
pressure  is  increased  by  feculent  accumulations  in  the  large  intes- 
tines, especially  in  the  sigmoid  flexure  of  the  colon;  by  tympani- 
tic distensions;  by  adipose  deposits  in  the  omentum,  mesentery, 
etc.;  and  especially  by  the  contraction  of  the  muscular  parietes  of 
the  abdomen  in  all  the  efforts  of  standing,  walking,  running,  strain- 


320      NATURAL    POSITION    AND    SUPPORTS    OF    UTERUS. 

ing  in  defecation,  vomiting,  sneezing,  coughing,  lifting  weights, 
etc.  It  is  no  wonder,  therefore,  that  we  hear  of  displacements  of 
the  uterus ;  but  rather,  that  the  natural  position  can,  in  any  indi- 
vidual, be  maintained  against  such  great  and  constant  weight  and 
pressure.  This  astonishment  is  not  diminished  when  we  find  that 
the  strong  and  hard  working  women  are,  perhaps,  less  liable  to 
displacements  than  the  delicate  and  feeble. 

The  interesting  question,  partly  mechanical,  and  partly  physio- 
logical, arises — how  can  the  uterus  be  maintained  in  its  position, 
in  opposition  to  such  powerful  sources  of  depression  ?  The  an- 
swers given  to  this  important  query  have,  perhaps,  not  as  yet 
been  entirely  satisfactory,  if  we  may  judge  from  the  discrepancies 
of  opinion  among  medical  men,  and  the  hints  which  are  occa- 
sionally still  thrown  out  by  anatomists  and  practitioners. 

What  are  the  natural  supports  of  the  uterus?  How  are  they 
arranged  so  as  to  maintain  it  in  the  direction  of  the  axis  of  the 
superior  strait,  with  its  body  floating  among  the  intestines,  the 
fundus  not  impinging  against  the  pubis,  or  against  the  sacrum  ? 
nor  the  vaginal  extremity  injuriously  pressing  against  the  floor 
of  the  pelvis,  during  all  the  varying  motions  and  eflbrts  of  the 
body  ? 

There  can  hardly  be  a  doubt  but  that  the  proper  position  of 
the  uterus  is  maintained  chiefly  by  the  ligaments,  as  will  be  here- 
after shown  ;  although  these  have  been  by  many  deemed  insufii- 
cient. 

The  Vagina. — The  idea  that  the  vagina  is  the  chief  support  of 
the  uterus  is  maintained  by  some.  Hence,  to  contract,  strengthen, 
or  diminish  the  size  of  the  vagina,  even  by  surgical  operations, 
has  been  and  still  is  regarded  as  an  important  means  in  the  treat- 
ment of  displacements  of  the  uterus.  All  this  is  contrary  to  just 
theory  and  positive  experience. 

The  vagina  is  a  soft,  flexible,  and  distensible  canal  of  a  flattened 
form,  having  no  firm  attachments,  excepting  at  its  lower  extremity. 
Experience  also  shows  that  it  accommodates  itself  to  the  ever  vary- 
ing position  of  the  cervix  and  body  of  the  uterus,  connected  with 
its  upper  or  sacral  extremity.  It,  therefore,  is  lengthened  out  in 
pregnancy;  it  is  shortened  or  curved  in  the  various  displacements 
of  the  organ;  sometimes  it  even  protrudes  at  the  vulva,  and  de 
ficends  with  the  uterus  between  the  limbs.  Moreover,  even  if  the 
vagina  were  a  straight  column,  and  the  uterus  pressed  directly  upon 


LIGAMENTS.  321 

it,  the  tube,  from  tlie  weakness  of  its  walls,  would  yield  and  sink 
under  tlie  weight;  but  the  vagina  is  curved,  and  meets  the  uterus 
at  an  acute  angle,  and  can  therefore  have  no  effect  in  preventing 
the  descent  of  the.  organ  towards  the  perineum,  or  the  falling  of 
the  fundus  anterior Ij^"  or  posteriorly.  Even  if  it  were  a  rigid  tube, 
fixed  throughout  its  whole  length  as  it  is  only  at  its  lower  ex- 
tremity, the  uterus  attached  to  its  upper  portion  could  sink  low 
towards  the  coccyx,  or  the  fundus  might  incline  towards  the 
pubis,  or  the  sacrum ;  but,  being  soft  and  very  flexible,  there  can 
be  little  or  no  support  given  by  this  canal. 

Observation  confirms  this  statement:  women  who  have  borne 
children  have  a  very  relaxed  and  distensible  vagina,  and  yet  gene- 
rally there  is  no  displacement  of  the  uterus ;  while,  on  the  other 
hand,  in  very  many  who  have  had  no  children,  and  even  in  vir- 
gins, when  there  is  great  contraction  and  tonicity  of  the  vagina, 
displacements  are  observed.  In  cases  also  of  atresia  vaginae, 
when,  from  inflammation,  adhesions,  induration,  and  contraction 
of  the  tube  have  ensued,  even  in  such,  we  meet  with  displace- 
ments of  the  womb. 

Case. — In  a  case  of  this  kind,  where  a  lady  had  been  suffering 
from  spinal  and  cerebral  irritation,  for  many  years,  the  vagina 
was  found  contracted  to  half  its  natural  length,  its  cavity  nearly 
obliterated,  and  the  uterus  in  a  state  of  partial  retroversion,  its 
posterior  surface  lying  upon  the  lower  part  of  the  rectum. 

Further,  no  degree  of  contraction  of  the  vagina,  whether  natu- 
ral, or  accomplished  by  astringents  or  by  surgical  operations,  will 
prevent  or  cure  any  displacement  of  the  uterus,  so  as  to  place  or 
retain  its  axis  in  the  direction  of  that  of  the  superior  strait  of  the 
pelvis.  The  only  apparent  exception  is  that  of  procidentia  uteri, 
where  the  organ  has  projected  out  of  the  body:  in  such  cases,  by 
contracting  or  obliterating  the  canal  of  the  vagina,  or  b}'-  closing 
the  vulva,  the  uterus  may  be  kept  within  the  body;  but  even  then, 
its  proper  position  in  the  pelvis  will  not  be  gained,  and  the  pa- 
tient may  continue  to  suffer. 

Ligaments. — That  the  uterus  is  maintained  in  situ  naturali 
by  its  ligaments,  assisted  by  several  accessories,  will  probably 
be.  acknowledged,  if  careful  attention  be  paid  to  the  natural 
oblique  position  of  the  organ  and  the  modus  operandi  of  these 
supports. 
21 


322      NATURAL    POSITION    AND    SUPPORTS    OF    UTERUS. 

Broad  Ligaments. — The  broad  ligaments,  or  ligamenta  lateralia, 
are  formed  of  two  lamina  of  the  peritoneum,  stretching  along 
each  side  of  the  uterus,  from  the  Fallopian  tubes  to  the  insertion 
of  the  vagina,  and  laterally  to  the  sides  of  the  pelvis;  they  are 
greatly  strengthened,  not  merely  by  areolar  tissue,  but  also  by 
arteries,  veins,  absorbents,  and  nerves,  which  run  between  the 


POSIEKIOK     VIEW     OF     THE     DTERUS     AND     ITS    LIGAMENTS. 


laminre.  These  ligaments  are,  therefore,  dense  and  strong  tissues. 
Their  attachment  to  the  sides  of  the  pelvis  will  be  found  to  cor- 
respond to  a  line  drawn  parallel  to  the  anterior  margin  of  the 
great  sacro-sciatic  notch.  This  line  is  nearly  vertical  when  the 
woman  is  on  her  back,  and  therefore  oblique  when  she  is  erect. 
Thus,  the  uterus  has  not  merely  a  strong  support  from  these 
broad  ligaments,  suspending  it  in  the  central  portions  of  the  pelvis, 
but  by  them  its  obliquity  is  maintained.  The  outer  attachments 
are  fixed  to  the  sides  of  the  pelvis,  and  this  being  oblique  in  the. 
erect  position,  gives  the  same  obliquity  to  the  ligaments  and  to 
the  uterus  between  their  folds. 

Mound  Ligaments. — The  round  ligaments,  or  ligam.enta  rotunda^ 
are  connected  with  the  cornua  of  the  uterus,  immediately  below 


ROUND    LIGAMENTS. 


323 


the  origin  of  the  Fallopian  tubes.  They  are  situated  between 
the  laminae  of  the  broad  ligaments,  and  run  somewhat  obliquely 
in  contact  with  the  anterior  layer,  through  which  they  are  visi- 
ble, to  the  sides  of  the  pelvis.  They  gradually  rise  towards  the 
superior  strait,  in  an  anterior  direction,  so  as  eventually  to  reach 


VIEW     OF    THE     UTERUS     AND     ITS     LIGAMENTS     IN     THE    DIKECTION     OF     THE 
AXIS    OF     SUPERIOR    STRAIT. 


the  internal  abdominal  rings;  they  then  pass  along  the  abdominal 
canals,  through  the  external  abdominal  rings,  and  are  lost  in  the 
fibrous  tissue  of  the  mons  veneris.  The  line  of  direction  is  ob- 
liquely outwards  and  forwards,  from  the  upper  portion  of  the  uterus 
to  the  internal  abdominal  rings.  This,  therefore,  is  the  direc- 
tion of  their  force  or  resistance,  and  covered  as  they  are  by  the 
anterior  peritoneal  laminae  of  the  broad  ligaments,  they  must,  if 
at  all  operative,  maintain  the  obliquit}'-  of  these  ligaments,  and 
also  of  the  uterus.     By  them  the  fundus  of  the  uterus,  and  the 


32-1:      NATURAL    POSITION    AND    SUPPORTS    OF    UTERUS. 

anterior  superior  folds  of  the  broad  ligaments,  are  kept  forwards. 
The  fundus  cannot  fall  backward  while  their  action  is  perfect. 

These  cords  are  not,  however,  strictly  ligamentous;  but,  as  is 
now  well  known,  they  contain  muscular  fibres.  When  they 
contract,  therefore,  the  fundus  is  positively  drawn  forwards  ;  they 
do  not  afford  merely  a  physical  resistance,  but  they  have  a  vital 
strength,  a  vital  tonicity,  and  are  capable  of  vital  contraction. 
As  all  these  tissues  are  buried  in  the  interior  of  the  body,  and 
are  covered  by  the  intestines,  no  ocular  proof  can  well  be  given 
of  this  contractility.  It  is,  however,  perfectly  just  to  suppose, 
that  their  contraction  will  draw  the  fundus  forwards,  while  their 
relaxation,  or  their  want  of  tone,  will  allow  the  fundus  to  fall 
backwards ;  and  that  a  strong  muscular  woman  will  also,  cxteris 
2')iirilms^  have  stronger  round  ligaments  than  the  delicate,  asthenic 
child  of  luxury,  and  hence,  she  will  not  be  so  predisposed  to 
posterior  displacements  of  the  fundus. 

It  may  be  added,  that  this  muscular  power  in  the  round  liga- 
ments maintains  a  certain  degree  of  tension  in  the  broad  ligaments, 
and  assists  them  in  the  performance  of  their  duties. 

Utero-  Vesical  Ligaments. — The  two  inferior  anterior  ligaments 
of  the  uterus,  usually  termed  the  utero-vesical  ligaments,  are  deli- 
cate folds  of  the  peritoneum,  and  pass  from  the  inferior  portions 
of  the  edges  of  the  uterus  to  the  sides  of  the  bladder.  They  seem 
to  have  no  other  effect  than  to  strengthen  the  connection  of  the 
inferior  portion  of  the  uterus  with  the  bladder.  Thence,  we  can 
explain  why  the  bladder  is  so  frequently  involved  in  the  symp- 
toms of  displacements  of  the  uterus. 

Utero- Sacral  Ligaments. — The  inferior  posterior  ligaments  of 
the  uterus,  the  utero-sacral  ligaments,  are  far  more  decisive  in 
their  formation,  and  important  in  their  influences.  In  dissections, 
after  the  small  intestines  are  removed  from  the  pelvis,  these  liga- 
ments are  immediately  recognized,  extending  from  the  sides  of 
the  cervix  uteri,  posteriorly  to  the  sacrum  on  either  side  of  the 
rectum.  They  diverge  from  each  other  as  they  approximate  the 
inferior  portions  of  the  sacrum,  so  that  the  rectum  lies  between 
them.  They  consist  of  two  laminae  of  peritoneum,  containing, 
between  them  some  muscular  fibres  from  the  uterus,  so  that  they 
also  have  tonicity  and  some  power  of  contraction.  The  perito- 
neum, on  the  posterior  surface  of  the  uterus,  continues  along  the 
neck  of  the  uterus  and  the  upper  third  of  the  vagina ;  it  is  then 


UTERO-SACRAL    LIGAMENTS,  825 

reflected  between  the  utero-sacral  ligaments  to  the  anterior  sur- 
face and  sides  of  the  rectum.  Thus,  a  deep  pocket  or  "  cul-de- 
sac,"  is  formed  behind  the  womb,  having  this  organ  and  the 
upper  third  of  the  vagina  anteriorly,  the  two  utero-sacral  liga- 
ments laterally,  and  the  rectum  and  sacrum  posteriorly.  This 
pocket,  as  well  as  the  whole  of  the  space  behind  the  broad  liga- 
ments, is  occupied  by  coils  of  small  intestines. 

It  is  manifest  from  the  above  description,  that  any  influence 
exerted  by  the  utero-sacral  ligaments,  whether  by  their  physical 
or  vital  powers,  must  be  to  keep  the  neck  of  the  uterus  towards 
the  sacrum.  Thence,  the  lower  part  of  the  uterus  is  kept  back- 
wards by  the  resistance  of  the  utero-sacral  ligaments.  The  os 
and  cervix  uteri  cannot  of  course  approximate  the  os  vaginae 
without  a  previous  relaxation  of  these  ligaments.  They  assist, 
therefore,  in  maintaining  the  obliquity  of  the  uterus,  by  keeping 
the  OS  uteri  pointing  towards  the  coccyx. 

General  Eemarks. — Such  are  the  chief  supports  of  the  uterus 
in  the  pelvis;  and,  the  more  they  are  examined  as  to  their  struc- 
ture, and  as  to  their  location  and  operation,  the  more  admirable 
and  efficient  will  they  appear. 

They  are  all  suspensory.  If  they  maintain  their  tonicity,  the 
uterus  remains  suspended  b\^  their  joint  efforts  in  the  central 
portions  of  the  pelvis,  and  with  its  axis  corresponding  to  that  of 
the  superior  strait.  They  all  resist  any  descent  of  the  uterus, 
while  the  falling  back  of  the  fundus  is  powerfully  counteracted 
by  the  round  ligaments,  assisted  by  the  utero-sacral,  keeping  the 
neck  of  the  organ  backwards.  This  effect  is  increased  by  their 
simultaneous  resistance  in  opposite  directions,  as  the  one  acts 
upon  the  superior,  the  other  on  the  inferior  extremity  of  the 
organ. 

If  these  ligaments  were  perfectly  rigid,  like  bone  or  metal, 
the  womb  would  be  fixed  in  its  central  position,  with  the  os  uteri 
towards  the  coccyx,  and  its  fundus  towards  the  linea  alba.  But 
as  they  are  all  pliable  and  elastic,  and  some  of  them  muscular  in 
their  structure,  they  allow  some  degree  of  mobility  to  the  uterus, 
and,  within  certain  limits,  by  their  physical  and  contractile 
powers  restore  it  again  to  its  proper  position,  when  it  has  been 
displaced.  The  uterus,  therefore,  being  a  movable  viscus,  may 
descend  when  much  pressure  is  made  from  above,  and  its  fundus 


326      NATURAL    POSITION"    AND    SUPPORTS    OF    UTERUS. 

may  be  pushed  backwards,  from  distension  of  the  bladder,  or 
forwards  when  the  bladder  is  empty,  by  distension  of  the  rectum, 
sigmoid  flexure  of  the  colon,  and  the  small  intestines.  When 
these  causes  are  not  operative,  it  can  resume  its  proper  position 
from  the  action  of  its  ligaments,  and  of  course  the  more  readily 
if  these  ligaments  retain  their  natural  tonicity,  as  in  the  young 
and  vigorous,  who  have  not  borne  children. 

The  immense  utility,  indeed  the  absolute  necessity,  of  this 
mobility  of  the  uterus,  must  be  evident  on  the  least  reflection ; 
but,  unfortunately,  it  has  been  too  frequently  forgotten,  as  will 
hereafter  be  shown,  in  the  treatment  of  its  displacements. 


ACCESSORY  AGENTS. 

Besides  the  ligaments,  which  are  the  main  supports  by  which 
the  uterus  is  suspended  in  the  pelvis,  and  maintained  in  its 
oblique  position  as  regards  the  axis  of  the  body,  there  are  acces- 
sory agents  of  considerable  importance,  which  have  not  generally 
been  recognized. 

Pelvic  Fascia. — This  aponeurotic  membrane,  which  may  be 
considered  as  continuous  with  the  fascia  iliaca,  and  which  re- 
ceives numerous  fibres  from  the  tendon  of  the  psoas  parvus 
muscle,  descends  from  the  linea  ilio-pectinea,  or  superior  strait 
of  the  pelvis,  closely  adherent  to  the  bones  of  the  pubis  and 
ilium,  until  it  reaches  the  upper  margin  of  the  thyroid  foramen. 
Here  it  appears  to  divide  into  two  laminae;  the  one,  continuing 
on  the  side  of  the  pelvis,  and  over  the  obturator  internus  muscle, 
forms  the  obturator  fascia,  etc.;  the  other,  or  more  internal, 
passes  over  the  levator  ani  muscle  to  ^the  vagina  and  rectum. 
Anteriorly,  portions  of  this  internal  lamina  are  reflected  to  the 
bladder,  thus  forming  a  part  of  the  utero-vesical  ligaments ;  and 
laterally,  reflections  pass  to  the  sides  and  superior  surface  of  the 
vagina,  and  to  the  neck  of  the  uterus  above  the  insertion  of  the 
vagina ;  while  posteriorly,  beyond  the  uterus,  some  fibres  go  to 
the  utero-sacral  ligaments,  increasing  their  strength  and  efficiency. 

The  Levatores  Ani  Muscles  arise  between  the  two  laminse 
of  the  pelvic  fascia,  from  the  symphysis  pubis  to  the  spinous 
process  of  the  ischium.  This  origin  is  marked  at  the  superior 
portion  by  a  circular  white  line.     These  muscles,  from  this  exten- 


MUSCLES  —  INTESTINES.  327 

sive  origin,  descend  to  the  rectum,  anus,  etc.,  and  constitute,  of 
themselves,  the  muscular  floor  of  the  pelvis,  while  their  aponeu- 
rotic covering,  the  internal  lamina  of  the  pelvic  fascia,  as  just 
mentioned,  extends  to  the  vagina,  the  neck  of  the  uterus,  and  to 
the  utero-sacral  ligaments.  In  females  who  have  not  borne  chil- 
dren, this  floor  has  considerable  firmness  with  much  elasticity, 
and,  involving  as  it  does  the  cervix  uteri,  contributes  something 
to  the  maintenance  of  the  central  position  of  the  womb  in  the 
pelvis.  Even  after  child-birth,  it  contracts  so  much  that  its 
mechanical  influences  are  still  important.  This  floor,  covered 
internally  by  peritoneum,  receives  all  the  pressure  from  the 
straining  efforts  of  the  woman,  except  that  which  is  communi- 
cated to  the  rectum  in  the  peritoneal  cul-de-sac  between  the 
utero-sacral  ligaments. 

Pressuee  of  the  Small  Intestines. — Another  and  still  more 
influential  agent  in  maintaining  the  natural  position  of  the  uterus, 
and  especially  its  obliquity,  is  the  pressure  of  the  smaM  intestines 
upon  this  organ.  To  explain  this  paradoxical  assertion,  a  few 
undeniable  facts  must  be  remembered. 

The  mesentery,  connecting  the  small  intestines  with  the  poste- 
rior part  of  the  abdomen,  admits  of  so  much  mobility  of  these 
intestines  as  to  allow  them  to  fall  freely  into  the  cavity  of  the 
pelvis,  which  they  do  whenever  this  cavity  is  not  fully  occupied. 
Hence,  they  are  found  in  front  and  also  behind  the  broad  liga- 
ments ;  much  the  larger  portion  is  usually  behind,  where  there  is 
more  space,  owing  to  the  hollow  of  the  sacrum,  and  the  deep 
pocket  or  cul-de-sac  between  the  utero-sacral  ligaments  back  not 
only  of  the  uterus,  but  of  the  upper  third  of  the  vagina.  The 
intestines  descend  not  merely  from  gravity,  but  are  pressed  firmly 
into  the  unoccupied  portions  of  the  pelvis  by  the  contraction  of 
the  muscular  walls  of  the  abdomen  in  every  movement  of  the 
iodividual.  The  impaction  becomes  greater  the  more  powerful 
the  contraction,  as  in  ascending  heights,  running,  straining,  etc. 

Hence,  it  clearly  follows  that  the  small  intestines  behind  the 
uterus,  when  this  organ  is  in  situ,  and  the  bladder  not  inordi- 
nately distended,  act  as  an  almost  insuperable  impediment  to 
retroversion  of  the  uterus ;  while  those  folds  of  the  intestines 
which  are  anterior  to  the  broad  ligaments,  together  with  the 
bladder,  prevent  anteversion  of  the  uterus.     The  natural  obli- 


328      NATURAL    POSITION    AND    SUPPORTS    OF    UTERUS. 

qiiity  of  the  womb  is,  therefore,  maintained  by  the  Aveight  and 
pressure  of  the  intestines.  They  not  only  afford  the  softest  nidus 
or  bed  imaginable  for  it,  but  serve  to  sustain  its  proper  position 
by  presenting  barriers  to  its  displacement  either  anteriorly  or 
posteriorly.  This  obliquity  of  the  uterus  guards  even  against 
the  tendency  to  prolapsus  uteri.  A  little  reflection  will  show 
that  when  the  woman  stands  erect,  especially  if  the  bladder  be 
not  much  distended,  any  great  pressure  from  above  will  act 
almost  exclusively  on  the  posterior  surface  of  the  uterus.  Hence, 
the  anterior  surface  of  this  bod}^,  resting  as  it  does  upon  the 
bladder,  pelvic  fascia,  and  vagina,  will  be  opposed  to  the  plane 
of  the  perineum,  the  fundus  of  the  uterus  will  approximate  the 
pubis,  and  the  os  uteri,  instead  of  resting  upon  the  perineum,  as 
in  prolapsus — will  be  directed  more  towards  the  sacrum.  There 
Avill  be,  therefore,  a  disposition  under  great  muscular  effort  in 
jumping,  straining,  etc.,  to  anteversion  rather  than  to  simple  de- 
scent of  the  uterus. 

Obliquity  of  the  Pelvis. — There  is,  however,  another  anato- 
mical fact  which  greatly  neutralizes  even  this  tendency  to  direct 
descent. 

It  is  well  known,  but  should  be  more  constantly  borne  in  mind, 
that  the  obliquity  of  the  pelvis^  is  so  great  that,  when  a  woman 
stands  erect,  a  vertical  line  representing  the  axis  of  the  body  which 
in  its  descent  touches  the  anterior  surface  of  the  third  lumbar  ver- 
tebra, will  strike  against  the  bodies  of  the  ossa  pubis.  It  neces- 
sarily results  that  the  pressure  transmitted  through  the  intestines, 
occupying  the  lower  part  of  the  abdomen,  must  be  in  the  same 
direction,  and  therefore  their  direct  impulse  is  against  the  pubis. 
It  follows,  also,  that  this  pressure  of  the  superincumbent  viscera 
does  not  impinge  directly  on  the  top  or  fundus  of  the  uterus 
in  situ^  but  on  its  posterior  surface.  The  tendency,  therefore,  of 
all  the  pressure  from  above,  the  accumulative  weight  of  the 
superincumbent  viscera,  assisted  by  the  powerful  contractile  effort 
of  all  the  muscular  parietes  of  the  abdomen,  is  to  push  the 
fundus  of  the  uterus  directly  forwards  towards  the  pubis,  and  of 
course  to  produce  the  ascent  of  the  cervix  uteri  towards  the 
hollow  of  the  sacrum,  in  other  words,  to  cause  "  anteversion." 
But,  the  presence  of  the  bladder  and   small  intestines  in  front  of 

'  See  diagram,  p.  317. 


OBLIQUITY    OF    THE    PELVIS.  329 

the  broad  ligaments  prevents  tlie  forward  proclivity  of  the  fundus; 
and  the  packet  of  intestines  behind,  in  the  cul-de-sac  of  the  peri- 
toneum, between  the  rectum  and  vagina,  etc.,  prevents  the  ascent 
of  the  cervix.  In  other  words,  the  displacement  of  the  uterus, 
when  the  organs  are  healthy  and  in  a  natural  position,  is  resisted 
by  the  very  weight  and  pressure  from  above,  which,  under  other 
circumstances,  might,  and  often  does,  cause  its  displacement. 


.    GENERAL  REMARKS. 

Such  are  the  admirable  provisions  made  for  the  sustentation  of 
the  uterus.  They  are,  indeed,  so  effectual  that  no  bad  effects 
usually  result  among  healthy  and  laborious  women,  whether  in 
savage  or  civilized  life,  though  they  are  daily  on  their  feet  for 
many  hours,  and  are  constantly  making  great  muscular  effort  in 
their  various  occupations. 

The  fundamental  principles,  alluded  to,  are  the  obliquity  of  the 
pelvis,  necessitating  the  obliquity  of  the  uterus,  the  parallelism  of 
this  organ  to  the  pubis,  and  of  its  long  axis  to  the  axis  of  the 
superior  strait.  This  obliquity  is  maintained  by  the  similar 
oblique  attachments  of  the  ligamenta  lateralia,  and  the  conjoint 
action  of  the  ligamenta  rotunda  with  the  ligamenta  utero-sacralia, 
the  one  keeps  the  fundus  towards  the  pubis,  and  the  other  the 
cervix  towards  the  sacrum ;  while  the  pressure  of  the  intestines 
surrounding  the  uterus  is  so  directed  as  to  form  a  barrier  to  the 
anterior  and  posterior  displacements,  and,  even  by  the  indirectness 
of  its  action,  to  prevent  a  prolapsus  uteri.  All  these  agencies, 
acting  in  concert,  maintain  the  obliquity  of  the  uterus  as  regards 
the  axis  of  the  body,  and  yet  permit  a  certain  degree  of  motion 
to  this  organ.  Thus,  when  the  bladder  is  distended,  it  is  pushed 
backwards  towards  the  sacrum ;  when  this  viscus  is  emptied,  and 
the  intestines,  particularly  the  sigmoid  flexure  of  the  colon  and 
of  the  rectum,  are  distended  in  the  ever-varying  condition  of  the 
alimentary  canal,  the  uterus  will  be  pressed  towards  the  pubis. 
So,  also,  in  all  the  muscular  movements  of  the  body,  the  womb 
will  be  more  or  less  depressed,  but  will  again  rise  as  soon  as  the 
effort  has  ceased.  The  ligaments  of  the  uterus  are  so  elastic  and 
yielding  as  readily  to  allow  these  necessary  movements  with  im- 
punity ;  and,  at  the  same  time,  have  such  strength  and  contrac- 
tility as  to  bring  the  organ  back  to  its  normal  oblique  position. 


330      VARIETIES    OF    DISPLACEMENTS    OF    THE    UTERUS". 


CHAPTER   II. 

VARIETIES   OF   DISPLACEMENTS   OF    THE   UTERUS, 
AND   THEIR   CAUSES. 

The  natural  position  of  the  uterus,  as  just  described,  is  perfectly 

>  consistent  witli  the  welfare  and  comfort  of  the  individual ;  any 

material  departure  from  it  must  be  regarded  as  unnatural,  and 

may  sooner  or  later  cause  discomfort,  or  positive  mischief.     Such 

deviations  are  usually  termed  disijlacements  of  the  uterus. 


VARIETIES. 

There  are  several  varieties  of  displacements,  which  have  been 
well  and  systematically  arranged  under  four  general  heads  or 
divisions,  viz..  Prolapsus,  Anteversio,  Retroversio,  and  Procidentia 
Uteri.  Each  variety,  with  its  complications,  should  be  well  de- 
fined and  clearly  comprehended. 

No  allusion  is  here  made  to  lateral  and  upward  displacements, 
as  they  will  be  noticed  among  the  complications  arising  from 
pelvic  tumors. 

Prolapsus. — By  prolapsus  uteri  should  be  understood  the 
simple  descent  of  the  organ,  so  that  the  extremity  of  the  neck 
of  the  uterus  impinges  unnaturally  on  the  posterior  wall  of  the 
vagina,  and  yet  the  axis  of  the  uterus  does  not  materially  depart 
from  its  parallelism  with  the  axis  of  the  superior  strait.  It  em- 
braces, therefore,  merely  those  cases  of  displacement  where  the 
fundus  continues  to  point  towards  the  linea  alba.  If  the  top  or 
fundus  be  anywhere  between  the  bones  of  the  pubis  and  the  pro- 
montory of  the  sacrum,  without  pointing  against  the  os  pubis  in 
front  or  the  sacrum  posteriorly,  and  the  neck  presses  firmly  on 
the  bottom  of  the  pelvis,  it  is  a  case  of  prolapsus.  The  uterus 
may  be  near  to  the  pubis,  or,  far  back,  near  to  the  sacrum  ;  but 


PROLAPSUS    OF    THE    UTERUS, 


331 


PROLAPSUS. 


PROLAPSUS     WITH     FLEXION, 


332      VARIETIES    OF    DISPLACEMENTS    OF    THE    UTERUS. 

the  top  still  points  upwards,  and  the  small  intestines  fall  in  front 
and  also  behind  the  organ,  maintaining  essentially  its  parallelism 
with  the  axis  of  the  superior  strait. 

"We  have  known  some  cases  of  "  falling  of  the  womb,"  in  which 
the  orifice  of  the  vagina  seemed  to  be  obstructed  by  the  neck  of 
the  uterus — so  near  was  it  to  the  body  of  the  pubis,  with  the 
anterior  part  of  the  neck  opposite  the  orifice  of  the  vagina,  and 
the  OS  uteri  resting  on  the  internal  surface  of  the  perineum.  In 
other  cases  of  prolapsus,  the  anterior  wall  is  so  far  removed  from 
the  symphysis  pubis,  as  to  demand  the  whole  length  of  the  index 
finger,  to  reach  the  front  of  the  uterus. 

Comjjlications. — The  degree  of  prolapsus  must  vary  according 
to  the  degree  of  relaxation,  or  yielding  of  the  ligaments,  and  the 
weight  and  pressure  from  above.  Not  unfrequently,  therefore, 
some  change  is  effected  in  the  form  of  the  uterus,  although  its 
tissue  is  naturally  very  firm,  by  the  force  with  which  it  is  pressed 
against  the  rectum  and  perineum.  Sometimes,  the  extremity  of 
the  cervix  is  flattened;  more  generally,  the  anterior  lip  of  the  os 
uteri  seems  to  be  prolonged,  and  the  posterior  lip  flattened.  Still 
more  frequently,  there  is  a  bending  of  the  neck  of  the  uterus,  so 
that,  while  the  proper  direction  of  the  body  is  still  maintained, 
there  is  an  alteration  in  that  of  the  inferior  portion  of  the  cervix, 
the  OS  uteri  looking  forward  to  the  orifice  of  the  vagina,  instead 
of  towards  the  coccyx.  This  is  now  termed  "  flexion"  of  the 
womb,  "  flexio  uteri,"  or  more  strictly,  it  \q  prolapsus  with  flexion. 
Hence,  the  simple  word  "  flexion,"  should  always  be  associated 
with  the  idea  of  descent  of  the  womb,  so  great  as  to  cause  a 
bending  of  its  tissue.  It  is  a  decided  case  of  prolapsus,  with  this 
complication. 

AXTEVEESION. — Anteversio  uteri  is  the  falling  forward  of  the 
fundus  to  such  a  degree,  that  it  impinges  against  the  bladder  and 
pubis;  while  the  os  uteri  points  toward  the  lower  or  middle 
portion  of  the  sacrum,  in  proportion  to  the  descent  of  the  fundus 
behind  the  symphysis.  If  this  description  be  correct,  this  variety 
of  displacement  is  comparatively  rare;  for,  although  the  fundus 
is  often  found  inclining  forward  to  a  considerable  degree,  yet, 
as  far  as  we  have  observed,  no  morbid  symptoms  have  resulted, 
unless  it  points  towards  the  pubis.  Hence,  to  these  last  cases 
the  word  should  be  restricted.     In  anteversion  of  the  uterus,  the 


ANTEVERSION    OF    THE    UTERUS. 

•N, 


383 


AXTEVEKSION, 


ANTEVERSION  WITH  FLEXMON, 


334      VARIETIES    OF    DISPL  A  CEMEXTS    OF    THE    UTERUS. 

pressure  of  the  small  intestines  seems  to  be,  almost  exclusively, 
on  the  posterior  surface  of  the  organ;  and  hence  every  muscular 
effort  in  standing,  straining,  etc.,  must  serve  to  depress  the  fundus 
more  and  more,  and  thus  aggravate  the  distress  of  the  patient. 

Complication. — These  cases  are  often  complicated  with  flexion 
of  the  neck  of  the  uterus,  so  that  while  the  fundus  and  body  are 
far  forward,  as  in  common  cases  of  anteversion,  the  neck  may  be  ' 
in  situ  naturali,\hQ  os  uteri  pointing  towards  the  coccyx,  or  even, 
if  the  flexion  be  still  greater,  towards  the  anterior  portion  of  the 
perineum.  This  is  "  anteversion  with  flexion^''''  or  more  shortly, 
"anteflexion  of  the  uterus." 

To  form  a  correct  diagnosis  requires  attention,  as  on  a  careless  j 
examination,  the  neck  being  found  in  its  proper  position,  the' 
practitioner  may  not  notice  the  displacement  of  the  fundus,  and 
the  flexion  in  the  neck. 

Anteflexion  must  arise  from  great  pressure  on  the  posterior 
part  of  the  body  of  the  uterus,  while  the  ascent  of  the  lower  ex- 
tremity, towards  the  hollow  of  the  sacrum  is  resisted  by  the  weight 
of  the  intestines  behind,  by  the  attachments  of  the  cervix  to  the 
vagina,  and  to  the  pelvic  fascia. 

Retroversion. — Retroversio  uteri  is  the  turning  back  of  the 
fundus  into  the  concavity  of  the  sacrum,  and  therefore  includes 
all  those  cases  in  which  the  fundus  is  below,  or  underneath  the 
promontory  of  the  sacrum.  There  may  be,  therefore,  various 
degrees  or  stages  of  retroversion,  according  to  the  position  of  the 
fundus,  whether  pointing  towards  the  upper,  middle,  or  lower 
portions  of  the  sacrum,  or  pressing  on  the  os  coccygis,  or  peri- 
neum. In  these  last  it  is  "  complete"  retroversion ;  in  the  former, 
"partial"  or  "incomplete"  retroversion.  Of  course,  in  uncompli- 
cated cases,  the  degree  of  displacement  of  the  os  uteri  corre- 
sponds to  that  of  the  fundus,  pointing  either  towards  the  peri- 
neum or  the  OS  vaginae,  in  partial  retroversions,  and  towards  the 
pubis,  in  complete  retroversions  of  the  organ. 

The  great  peculiarity  of  retroversion  is,  that  the  weight  of  the 
intestines,  and  the  pressure,  therefore,  from  the  contraction  of  the 
muscular  walls  of  the  abdomen,  are  received  directly  on  the  ante- 
rior surface  of  the  uterus ;  and  this  gradually,  but  almost  certainly, 
increases  the  displacement  on  every  exertion  of  the  patient.  It  is 
thus  distinguished  from  prolapsus,  in  which  the  intestines  fall 


EETROVEESION    OF    THE    UTERUS. 


335 


RETROVEKSIOX. 


PARTIAL  RETROVERSION. 


336      VARIETIES    OF    DISPLACEMENTS    OF    THE    UTERUS. 

around  the  uterus,  posteriorly  and  anteriorly,  serving  to  maintain 
the  parallelism  of  its  axis  with  that  of  the  superior  strait.  It  also 
differs,  in  this  respect,  from  anteversion,  in  which  the  intestines 
press  on  the  posterior  surface  of  the  organ,  and  tend  to  push  the 
fundus  still  further  forward.  In  anteversion  and  retroversion, 
there  is  a  displacement  of  the  longitudinal  axis  of  the  womb, 
which  is  no  longer  parallel  to  the  axis  of  the  superior  strait,  bat 
becomes  oblique  to  this  axis,  crossing  it  at  an  angle,  which  varies 
according  to  the  degree  of  displacement.  In  retroversion,  there- 
fore, the  long  axis  of  the  womb  may  be  sometimes  coincident  with 
the  axis  of  the  inferior  strait;  sometimes  with  that  of  the  vagina; 
and  sometimes  even  with  that  of  a  line  from  the  lower  part  of  the 
sacrum  to  the  bodies  of  the  pubis,  that  is,  nearly  parallel  with  the 
coccy-pubic  or  antero-posterior  diameter  of  the  inferior  strait. 

Com}  )li  cat  ion. — Eetroversion  of  the  uterus  is,  however,  very 
frequently  complicated  with  "flexion"  at  the  cervix.  This  is 
retroversion  with  flexion^  or  "retroflexion"  of  the  uterus.  Some- 
times, the  bending  of  the  neck  is  very  regular;  but,  not  unfre- 
quently,  it  is  abrupt,  well  marked,  and  usually  towards  the  upper 
third  of  the  cervix.  In  these  cases  of  retroflexion,  the  womb  is 
so  nearly  of  the  form  of  the  chemist's  retort,  that  we  formerly 
called  it  "  the  retort-uterus." 

Flexion  of  the  neck  often  renders  the  diagnosis  of  retroversion 
difficult.  For  example,  the  os  and  cervix  may  be  perfectly  in  situ, 
yet  the  fundus  be  below  the  promontory,  and  perhaps  even  at  the 
lower  extremity,  of  the  sacrum,  according  to  the  degree  of  flexion 
which  exists  in  the  neck.  There  may  be  great  displacement  of 
the  body  of  the  uterus,  with  all  its  bad  consequences,  and  yet 
no  displacement  of  the  cervix.  If,  however,  the  fundus  be  low 
down,  at  or  near  the  perineum,  there  is  usually  also  some  devia- 
tion of  the  neck ;  so  that  the  os  uteri  will  generally  point  towards 
the  orifice  of  the  vagina,  instead  of  towards  the  coccyx — its  nor- 
mal direction — or  towards  the  symphysis  pubis,  as  in  simple 
cases  of  retroversion. 

The  causes  of  flexion  in  cases  of  retroverted  uterus,  are  analo- 
gous to  those  of  anteflexion,  namely,  the  resistance  offered  by  the 
attachments  of  the  vagina,  and  the  pelvic  fascia,  at  the  cervix, 
and  by  the  pressure  of  the  intestines  and  of  the  bladder.  All 
these  have  a  tendency  to  prevent  the  ascent  of  the  neck  behind 


-RETROVERSION    WITH    FLEXION, 


337 


KETKOVERSION  WITH  FLEXION. 


PARTIAL  KETKOVEKSION,  WITH  FLEXION. 


22 


338      VARIETIES    OF    DISPLACEMENTS    OF    THE    UTERUS. 

the  pubis,  while  the  fundus  is  forced  down  along  the  concavity 
of  the  sacrum. 

Procidentia. — "Bj procidentia  uteri  is  to  be  understood,  the  pro- 
jection of  the  organ  out  of  the  orifice  of  the  vagina.  It  may  be 
partial  or  complete  ;  it  is  partial  when  only  a  portion  of  the  uterus 


protrudes,  and  complete  when  the  whole  organ  is  exterior  to  the 
pudendum.  In  all  cases,  the  womb,  excepting  the  extremity  of 
the  neck,  is  necessarily  entirely  covered — and  of  course  con- 
cealed from  sight — by  the  vagina.  The  vagina  may  be  said  to  be 
inverted ;  instead  of  forming  a  canal  to  the  womb,  with  the  mu- 


PEOCIDENTIA.  839 

cons  membrane  inside,  it  presents  the  appearance  of  a  conical  or 
globular  body  outside  the  vulva,  and  with  the  mucous  surface  on 
the  exterior.  It  may  contain  not  merely  the  uterus,  but  fre- 
quently the  ovaries,  with  large  portions  of  the  round  and  broad 
ligaments,  of  the  small  intestines,  of  the  bladder,  and  sometimes 
of  the  rectum. 

The  degree  of  procidentia,  and  of  course  the  size  of  this  tumor, 
depend  on  the  degree  of  relaxation  of  the  tissues.  Authors 
mention  cases  in  which  it  was  of  an  enormous  size.  Under  these 
circumstances,  exposed  as  the  vagina  and  os  uteri  must  be  to 
external  irritation,  the  whole  tissue,  occasionally,  becomes  altered 
by  inflammatory  action.  Hence,  thickening  and  indurations  may 
result  to  such  an  extent  that  the  procidentia,  especially  when 
complicated  with  enlargements  of  the  uterus,  may  become  "  irre- 
ducible." We  have  seen  many  cases  of  this  displacement,  but 
they  have  all  been  "  reducible."  The  occurrence  of  procidentia 
necessarily  presupposes  great  relaxation  of  all  the  tissues;  this 
is  true,  not  merely  of  those  composing  the  ligaments,  fasciae,  and 
vagina,  but  also  of  those  belonging  to  the  perineum  and  vulva. 
Hence,  it  is  observed  chiefly  in  aged  women  who  have  borne 
many  children. 

It  is  generally  stated  that  procidentia  follows  a  prolapsus.  Yet, 
strictly,  it  is  not  prolapsus — mere  descent  in  the  normal  direction 
of  the  axis  of  the  uterus— but  retroversion,  that  must  precede  a 
procidentia.  The  fundus  must  fall  into  the  hollow  of  the  sacrum, 
and  even  descend  to  the  inferior  portion  of  this  bone,  before  the 
axis  of  the  uterus  can  become  coincident  with  that  of  the  vagina, 
A  prolapsus  may  precede  a  retroversion ;  but  there  must  be  a 
retroversion  before  there  can  be  a  procidentia  uteri. 


CAUSES. 

If  we  consider  merely  the  apparent  delicacy  of  the  ligaments  of 
the  uterus,  a  displacement  of  this  organ  would  seem  almost  inevi- 
table, even  under  the  ordinary  motions  of  the  body ;  but  when 
we  remember  the  obliquity  of  its  position,  maintained,  as  has 
been  explained,  by  the  harmonious  co-operation  of  the  lateral, 
anterior,  and  posterior  ligaments,  and  also  by  the  pressure  of  the 
bladder  and  intestines  in  front  and  behind,  we  would  infer  that 


3-iO       CAUSES    OF    DISPLACEMENTS    OF    THE    UTERUS. 

displacements  should  be  of  rare  occurrence.  This  idea  is  con- 
firmed by  the  acknowledged  fact,  that  a  very  large  proportion  of 
"women  have  no  suffering  from  this  source,  and  that  multitudes 
are  engaged  in  the  most  active  and  laborious  occupations  with 
perfect  impunity. 

Nevertheless,  displacements  do  at  times  occur,  existing,  it  may 
be,  without  any  perceptible  injury,  but  frequently  producing  or 
maintaining  the  most  severe  suffering,  mental  and  corporeal,  to 
which  the  human  system  is  liable. 

An  investigation  of  the  causes  becomes,  therefore,  all  import- 
ant. They  may  be  divided  advantageously  under  the  two  general 
heads  of  predisposing  and  exciting  causes.  The  former  should  be 
considered  separately,  although  operating  also  very  constantly  as 
exciting,  as  well  as  predisposing  causes. 

Predisposing  Causes.  Relaxation  of  the  Ligaments  and  of  the 
reflected  Pelvic  Fascia. — The  actual  condition  of  these  tissues  is 
not  perhaps  a  subject  of  positive  demonstration,  as  they  are 
situated  within  the  body,  and  can  neither  be  seen  nor  felt.  We 
may  safely  conclude,  however,  that  in  states  of  great  general 
weakness,  languor,  and  relaxation  of  the  system,  the  ligaments, 
which  are  partially  of  a  muscular  character,  partake  of  the  gene- 
ral exhaustion.. 

We  know,  moreover,  that  during  pregnancy  all  these  ligaments 
are  exceedingly  elongated,  as  well  as  developed.  Of  course,  for 
some  time  after  parturition  they  remain  long,  and  much  relaxed. 
Hence,  most  married  women  date  the  commencement  of  their 
sufferings  from  a  particular  abortion,  or  confinement  at  term. 
On  this  account,  pregnancy  is  to  be  regarded  as  predisposing  to 
displacements  of  the  uterus. 

Increased  Size  and  Weight  of  the  Uterus. — The  action  of  this 
cause  is  obvious,  for  the  larger  size  necessarily  presents  a  broader 
surface  to  the  superincumbent  viscera,  and  the  heavier  the  organ 
the  greater  the  strain  upon  its  supports.  The  frequency  and  the 
great  influence  of  this  cause  have  not  been  sufficiently  regarded. 

Although  the  ligaments  may  be  as  short  and  firm  as  natural, 
yet,  in  the  early  stages  of  pregnancy,  every  one  considers  some 
displacement  of  the  organ  as  almost  inevitable  for  a  few  weeks. 
Also,  there  is  a  strong  predisposition  to  displacement  after  de- 
livery, especially  about  the  tenth  day,  when  the  organ  is  large 


PREDISPOSING    CAUSES.  .  341 

and  heavy,  and  has  descended  completely  into  the  pelvis.  This, 
in  addition  to  the  relaxation  of  the  natural  supports  of  the  uterus, 
is  another  and  a  very  powerful  explanation  why  females  do  look 
upon  their  confinements  as  the  original  cause  of  their  troubles. 

There  are  various  other  sources  of  enlargement  of  this  organ, 
all  of  which,  therefore,  directly  or  indirectly,  facilitate  its  displace- 
ment. Such  are  hypertrophies,  indurations  from  inflammatory 
action,  cancerous  or  other  malignant  diseases,  physometra  or 
hydrometra,  intra-  and  extra-uterine  tumors,  or  tumors  in  the 
substance  of  the  organ.  In  many  of  these  cases,  there  is  a  con- 
stant displacement ;  but  in  others  it  takes  place  only  while  the 
woman  is  in  the  erect  position,  and  then  excites  such  sensations 
of  weight  and  pressure  as  to  prevent  her  from  taking  much  exer- 
cise. Under  this  division,  a  very  large  proportion  of  modern 
authorities  would  place  congestions  and  inflammations  of  the 
uterus,  even  insisting  that  the  kind  of  displacement  often  depends 
on  the  part  of  the  uterus  which  is  inflamed.  We  have  never 
been  able  to  perceive  any  ground  for  this  assertion.  Congestions 
of  the  uterus  are  of  every-day  occurrence,  arising  not  only  from 
the  periodical  menstrual  nisus,  but  from  all  those  mental,  moral, 
and  physical  irritations  peculiar  to  women.  Inflammations  also 
are  not  unfrequently  observed  in  the  cervix,  and  sometimes  in 
the  body,  but  especially  in  the  appendages  of  the  uterus,  without 
any  displacement  at  the  time  or  subsequently.  That  congestions 
and  sometimes  inflammation  coexist  witb  displacements,  there 
can  be  no  doubt,  but  that  they  are  the  cause  demands  much  more 
positive  proof,  than  has  hitherto  been  presented. 

Distension  of  the  Abdomen. — A  predisposition  to  displacement 
often  arises  from  pressure  made  on  the  uterus  by  distension  of  the 
abdomen,  due,  for  example,  to  constipation,  to  intestinal  or  peri- 
toneal tympanites,  to  ascites,  to  a  distended  bladder,  to  enlarge- 
ments of  the  ovaries,  of  the  glands  of  the  mesentery  or  of  the 
pelvis,  to  increased  size  of  the  liver,  spleen,  kidneys,  omentum, 
etc.,  and  to  extra -uterine  pregnancy. 

Pressure  on  the  Abdomen. — This  cause  operates  virtually  in  the 
same  manner  as  the  last  mentioned,  and  is  dependent  on  all 
those  circumstances  which  diminish,  or  have  a  tendency  to  dimi- 
nish, the  size  of  the  abdomen.  The  peritoneal  "cavity,"  so  called, 
is  in  reality  a  plenum.  Every  agent  which  tends  to  diminish  the 
size  of  the  abdomen  acts  as  a  compressor  to  the  viscera.     Hence 


842       CAUSES    OF    DISPLACEMENTS    OF    THE    UTERUS. 

all  pressure,  from  the  tight  dresses  and  corsets  to  which  women 
are  so  strangely  devoted,  from  the  weight  of  the  garments  tightly 
secured  around  the  waist,  from  abdominal  or  "  utero-abdominal" 
supporters,  must  act  as  a  depressing  force  on  the  body  of  the 
uterus,  and  constitute  at  least  a  predisposing  cause  of  uterine 
mal-positions. 

Menorrhagia^  etc. — Much  has  been  written  of  menorrhagia  and 
leucorrhoea,  of  relaxation  of  the  vagina,  perineum,  etc.,  as  facili- 
tating displacements  of  the  womb.  These  are  of  no  consequence, 
except  as  they  may  evince  a  corresponding  relaxation  of  the 
internal  tissues.  For  the  uterus  is  maintained  in  situ  by  its 
ligaments,  etc.,  as  above  shown,  and  not  by  the  vagina ;  so  that 
relaxation  of  this  canal  may  be,  and  often  is,  very  great,  with- 
out any  departure  of  the  uterus  from  its  natural  position. 

This  declaration  is  at  variance  with  that  expressed  by  almost 
all  authors,  but  we  have  had  so  many  examples  of  great  suffering 
from  displacement  of  the  uterus,  where  the  vagina  was  small, 
presenting  no  evidence  of  relaxation,  in  married  women,  and 
especially  in  virgins,  that  we  express  our  opinion  with  the  greatest 
confidence.  Moreover,  it  is  very  common  to  find  the  uterus  in 
situ  and  no  bad  symptoms  present,  where  the  vagina  is  large  and 
its  tonicity  has  disappeared. 

The  only  apparent  exception,  in  these  remarks,  is  in  cases  of 
procidentia  uteri,  with  or  without  cystocele  or  rectocele.  In  such 
cases  relaxation  of  the  vagina  and  vulva  facilitates  greatly  the 
descent  of  the  uterus  and  other  pelvic  viscera.  But  such  descent 
is  the  result  of  a  previous  relaxation  and  elongation  of  the  liga- 
ments of  the  uterus. 

Exciting  Causes. — The  predisposing  causes,  now  enumerated, 
may  exist  for  a  long  time,  in  many  individuals,  without  the  occur- 
rence of  any  decided  displacement.  This  is  especially  the  case 
when  the  individual  lives  a  quiet  life,  without  the  necessity  of 
much  muscular  exertion. 

Nevertheless,  these  predisposing  causes  are  often  adequate,  of 
themselves,  to  effect  a  displacement.  If  there  be  a  relaxation  of 
the  ligaments,  the  natural  weight  of  the  organ  and  the  usual 
pressure  from  the  intestines  will  force  the  uterus  out  of  its  posi- 
tion.    This  will  more  readily  occur  if  motion  be  resorted  to  soon 


EXCITING    CAUSES.  3i3 

after  parturition,  when  the  organ  is  larger  and  heavier  than  usual, 
and  its  ligaments  are  elongated. 

Also,  even  when  the  ligaments  are  of  their  proper  length  and 
X — :_:x_  —  • J   _: r  xt u  -f-^jji  q^^j  cause,  an  aug- 

or  a  diminution  of  its 
^ately  or  conjointly,  by 
3r  week,  or  even  year 

Doubtless  this  is  often 

r,  generally  occur  more 
[y,  in  consequence  of  a 
the  abdominal  viscera, 
3ular  effort.  This  may 
5,  but  much  more  rea- 

ommencement  of  their 
)r  defecation,  especially 

fatiguing  walk,  to  run- 
t  dancing,  to  an  effort 
3ns,  to  ascending  stairs 
)r  vomiting;  indeed,  to 
ominal  rmiscles  and  dia- 
era  are  simultaneously 
The  uterus,  situated  in 
eive  all  such  impulses, 
ports  often  yield  under 
e  organ  to  recede  from 

n,  with  or  without  pro- 
)y  the  development  of 
jterior  portions  of  the 
the  fundus  will  be  in- 
urface  it  will  generally 
„ „_placement  are  often  in- 
curable, the  cause  being  permanent,  although  they  may  be  greatly 
palliated. 

Displacements  are  also  often  determined  by  other  developments, 
as  by  osseous  growths  from  the  puhis  or  the  sacrum,  by  enlarged  glands, 
hy  the  cysts  of  an  extra-uterine  pregnancy,  hy  abscesses,  and  other  tume- 


842       CAUSES    OF    DISPLACEMENTS    OF    THE    UTERUS. 

all  pressure,  from  tlie  tight  dresses  and  corsets  to  which  women 
are  so  strangely  devoted,  from  the  weight  of  the  garments  tightly 
secured  around  the  waist,  from  abdominal  or  "  utero-abdominal" 
supporters,  must  act  ?^  ^  r^o,^vocc.iv,rv  fr^-n^^  ^^  -t-i^-  ■k^.i„  ^.c  ^.-u^ 

uterus,  and  constitute 
mal-positions, 

Menorrhagia,  etc. — !N^ 
leucorrhoea,  of  relaxai 
tating  displacements  o 
except  as  they  may  ( 
internal  tissues.  For 
ligaments,  etc.,  as  aho- 
relaxation  of  this  can 
out  any  departure  of  t 

This  declaration  is 
all  authors,  but  we  ha^ 
from  displacement  of 
presenting  no  evidenc 
especially  in  virgins,  tl 
confidence.  Moreover 
situ  and  no  bad  sympt 
its  tonicity  has  disappe 

The  only  apparent  ( 
procidentia  uteri,  with 
cases  relaxation  of  th 
descent  of  the  uterus  a 
is  the  result  of  a  prev 
ments  of  the  uterus. 

Exciting  Causes.— 
may  exist  for  a  long  tii 
rence  of  any  decided  ' 
when  the  individual  ] 
much  muscular  exertic 

Nevertheless,  these  ^         ^       ^ ^^ ,  ^. 

themselves,  to  effect  a  displacement.  If  there  be  a  relaxation  of 
the  ligaments,  the  natural  weight  of  the  organ  and  the  usual 
pressure  from  the  intestines  will  force  the  uterus  out  of  its  posi- 
tion.    This  will  more  readily  occur  if  motion  be  resorted  to  soon 


EXCITING    CAUSES.  313 

after  parturition,  when  the  organ  is  larger  and  heavier  than  usual, 
and  its  ligaments  are  elongated. 

Also,  even  when  the  ligaments  are  of  their  proper  length  and 
tonicity,  an  increased  size  of  the  womb  from  any  cause,  an  aug- 
mentation of  the  contents  of  the  abdomen,  or  a  diminution  of  its 
cavity  from  pressure  externally,  may,  separately  or  conjointly,  by 
their  steady,  constant  influence  week  after  week,  or  even  year 
after  year,  gradually  effect  a  displacement.  Doubtless  this  is  often 
the  case. 

Muscular  Effort. — Displacements,  however,  generally  occur  more 
rapidly,  and  sometimes  even  instantaneously,  in  consequence  of  a 
fall,  a  severe  blow,  a  concussion  affecting  the  abdominal  viscera, 
or  more  frequently  from  some  violent  muscular  effort.  This  may 
happen  even  when  no  predisposition  exists,  but  much  more  rea- 
dily when  there  is  such  a  predisposition. 

Many  individuals,  therefore,  trace  the  commencement  of  their 
sufferings  to  straining  efforts  in  micturition  or  defecation,  especially 
when  made  soon  after  parturition. 

Others  attribute  the  accident  to  a  long,  fatiguing  walk,  to  run- 
ning, or  jumping,  to  prolonged  or  violent  dancing,  to  an  effort 
made  in  raising  weights  or  carrying  burdens,  to  ascending  stairs 
or  heights,  to  violent  sneezing,  coughing,  or  vomiting;  indeed,  to 
any  sudden  or  powerful  contraction  of  the  abdominal  muscles  and  dia- 
phragm. For  by  each  of  these,  all  the  viscera  are  simultaneously 
compressed,  and  often  with  great  force.  The  uterus,  situated  in 
the  inferior  portion  of  the  body,  must  receive  all  such  impulses. 
No  wonder,  then,  that  its  ligaments  and  supports  often  yield  under 
these  reiterated  impressions,  and  permit  the  organ  to  recede  from 
its  proper  position. 

Tumors^  etc. — Anteversion  or  retroversion,  with  or  without  pro- 
lapsus, may  not  unfrequently  be  caused  by  the  development  of 
heterologue  tumors,  on  the  anterior  or  posterior  portions  of  the 
uterus.  "When  on  the  posterior  surface  the  fundus  will  be  in- 
clined forward,  and  when  on  the  anterior  surface  it  will  generally 
be  inclined  backward.  Such  cases  of  displacement  are  often  in- 
curable, the  cause  being  permanent,  although  they  may  be  greatly 
palliated. 

Displacements  are  also  often  determined  by  other  developments, 
as  by  osseous  growths  from  the  pubis  or  the  sacrum,  by  enlarged  glands, 
by  the  cysts  of  an  extra-uterine  pregnancy,  by  abscesses,  and  other  tume- 


844      CAUSES    OF    DISPLACEMENTS    OF    THE    UTERUS. 

factions  in  the  pelvis.  They  are  still  more  frequently  the  result  of 
ovarian  enlargements.  A  small  ovarian  tumor  in  the  pelvis  may 
cause  a  "  lateral  displacement"  of  the  uterus,  noticed  by  some 
authors,  but  of  no  great  importance,  as  the  symptoms  resulting 
belong  rather  to  the  displaced  or  enlarged  ovary  than  to  the 
womb.  But,  of  course,  anteversion  and  retroversion  also  are  not 
unfrequently  the  consequence  of  such  ovarian  enlargements  when 
they  press  on  the  anterior  or  posterior  surface  of  the  uterus. 

The  character  of  the  displacement  must  depend  on  a  com- 
bination of  circumstances  not  to  be  easily  understood.  Some 
speculations  on  this  subject  may,  however,  be  broached. 

If  the  bladder  or  the  rectam  be  not  much  distended,  the  small 
intestines  will  be  driven,  by  the  muscular  exertions,  so  equably 
behind  and  before  the  uterus,  that  retroversion  or  anteversion 
will  probably  not  occur ;  but  prolapsus  or  descent  of  the  uterus 
will  result,  the  axis  of  the  organ  not  materially  departing  from 
its  parallelism  with  that  of  the  superior  strait. 

If  the  bladder  should  be  empty,  and  the  sigmoid  flexure  of  the 
colon  and  the  rectum  be  much  distended,  the  fundus  may  be  pre- 
cipitated against  the  pubis,  and  anteversion  result. 

Should,  however,  the  bladder  be  distended,  and  the  rectum 
empty,  then  any  sudden  impression  would  almost  inevitably  force 
the  fundus  of  the  uterus  under  the  promontory  of  the  sacrum,  so 
that  a  partial,  and  eventually  a  complete,  retroversion  would  be 
produced. 

In  cases  of  great  relaxation  of  the  tissues  of  the  pelvis  and 
of  the  perineum,  continued  succussions  from  the  abdominal  pa- 
rietes  would  eventually  cause  a  partial  or  complete  procidentia 
uteri,  with  the  consequent  displacements  of  the  bladder,  intes- 
tines, etc.  Procidentia  will  be,  as  already  shown,  the  immediate 
result  not  of  a  prolapsed,  but  of  a  retroverted  womb. 

Some  practitioners  have  attempted  to  account  for  the  occurrence 
of  anteversion  or  retroversion  of  the  uterus  by  the  hypothesis  that 
in  congestion,  inflammation,  or  induration  of  the  anterior  half  of 
the  organ  its  size  and  weight  are  so  increased  that  it  falls  forward, 
thence  anteversion ;  but  if  the  posterior  half  be  similarly  affected, 
then  its  greater  size  and  weight  cause  retroversion  /  Hence,  partial 
inflammation  or  induration  of  the  uterus  is  the  cause  of  such 
displacements;  and  being  removed,  the  displacements  disappear! 


SPECIAL    CAUSES.  3l5 

It  would  certainly  be  very  difficult  for  an  educated  pathologist 
to  imagine  that  during  life  any  congestion  or  inflammation  could 
be  confined  to  one-half  of  an  organ  so  vascular  as  the  womb ;  and 
perhaps  it  would  be  more  difficult  for  an  accurate  and  experienced 
anatomist  to  demonstrate,  upon  a  post-mortem  examination,  an 
induration  from  inflammation  affecting  merely  the  anterior  or  the 
posterior  segment  of  the  uterus.  If,  however,  these  hypotheses, 
or  anatomical  researches  be  confirmed,  would  the  laws  of  mecha- 
nics justify  the  supposition  that  ante  version  in  the  one  case,  or 
retroversion  in  the  other,  would  result?  We  trow  not.  The 
increased  weight,  if  it  had  any  influence  as  regards  these  dis- 
placements, would,  owing  to  the  natural  obliquity  of  the  uterus, 
be  always  in  an  anterior  direction,  where  it  would  be  received  by 
a  packet  of  the  small  intestines,  and  by  the  often  distended  bladder. 
But  it  should  be  remembered  that  in  these  supposed  cases  there 
is  an  increase  of  size  also,  which  would  actually  necessitate  a 
directly  opposite  result  to  that  maintained  by  these  authorities. 
It  is  evident,  upon  a  little  thought,  that  if  the  anterior  portion 
of  the  uterus  be  augmented  in  size,  the  fundus  uteri  must  neces- 
sarily approximate  the  sacrum  more  and  more  as  the  swelling  of 
this  surface  increases,  and  presses  upon  the  bladder  and  pubis, 
thus  predisposing  to,  or  actually  causing,  not  an  anteversion,  which 
was  anticipated,  but  a  retroversion  of  the  organ.  So  also,  if  the 
posterior  portion  be  enlarged,  the  fundus  will  as  inevitably  be 
pushed  forward,  so  that  a  tendency  to  anteversion^  not  to  retrover- 
sion, would  ensue. 

If  this  view  needed  confirmation,  we  have  a  demonstration  of 
its  truth  in  preternatural  conditions  of  the  uterus ;  for  example,  in 
cases  where  a  tumor  or  tumors  of  larger  or  smaller  growth  are 
developed  on  the  anterior  part  of  the  organ,  the  fundus  is  found 
tending  to  the  sacrum  in  proportion  to  the  size  of  the  tumor.  But 
if  the  tumor  be  on  the  posterior  surface  the  fundus  as  necessarily 
inclines  forwards,  towards  the  pubis.  The  supposition,  then,  that 
anteversion  or  retroversion  is  the  result  of  simple  weight,  may  be 
considered  as  altogether  gratuitous. 


346      SYMPTOMS    OF    DISPLACEMENTS    OF    THE    UTERUS. 


CHAPTER    III. 

SYMPTOMS   OF  DISPLACEMENTS   OF   THE   UTERUS. 

The  symptoms  of  displacements  of  the  uterus  constitute  a  difficult 
subject  of  investigation,  if  we  may  judge  from  the  various  and  dis- 
crepant opinions  of  scientific  and  experienced  pathologists.  Many 
ignore  all  these  malpositions,  regarding  them  of  no  importance  in 
theory  or  in  practice.  They  say  that  if  the  disease  be  cured,  the 
displacement  will  disappear  or  excite  no  trouble.  Others  are  dis- 
posed to  refer  every  morbid  phenomenon  simply  to  the  malposi- 
tion, intimating  that  a  woman  cannot  feel  well  when  the  organ 
is  not  in  its  normal  position.  Between  these  extremes  there  is 
every  modification  of  opinion,  and,  of  course,  of  practice.  These 
will  not  be  examined  in  detail,  but  the  author  will  merely  state  the 
results  of  his  analysis  of  the  symptoms.  This  will  be  done  with 
the  more  confidence  as  the  views  and  principles  enunciated  were 
not  formed  "a  priori,"  but  have  been  derived  from  careful  clinical 
observations,  made  during  a  laborious  practice  extending  through 
many  years.  The  principles  thus  practically  deduced,  have  been 
tested  therapeutically  so  frequently,  that  the  author  feels  at 
liberty  to  'record  them  positively,  as  general  facts,  of  great  im- 
portance as  guides  for  the  practitioner,  but  of  course  modified 
by  the  innumerable  circumstances  and  idiosyncrasies  of  individual 
patients. 

DISPLACEMENTS  MAY  EXIST  WITH  IMPUNITY. 

The  first  general  declaration  to  be  made  is,  that  displacements 
of  the  uterus  exist  in  innumerable  cases,  with  apparent  impunity. 
There  may  be  no  decided  symptoms  to  intimate  that  the  accident 
has  occurred.  The  woman  may  feel  well,  and  all  her  functions 
may  be  easily  and  comfortably  executed.  In  various  tempera- 
ments, and  in  all  classes  of  society,  such  cases  may  be  met  with ; 


DISPLACEMENTS    WITHOUT    SUFFERING.  347 

but,  they  occur  cTiieflj  in  the  strong  and  laborious,  in  those  of  a 
cold,  phlegmatic  temperament,  and  in  northern  countries.  In  all 
such,  the  nervous  system  is  not  very  sensitive.  It  is  strong,  but 
not  excitable. 

Since  suffering  may  exist  without  displacement,  and  the  dis- 
placement frequently  without  suffering  ;  many  pathologists  have 
concluded  that  there  is  no  mutual  dependence  of  the  one  upon 
the  other,  and  have  attempted  to  relieve  the  suffering,  while  they 
allowed  the  displacement  to  remain. 

Experience — at  least  our  experience — is,  however,  so  directly 
in  opposition  to  this  practical  deduction,  that  it  is  impossible  to 
admit  it.  It  is  very  difficult  to  relieve  the  suffering,  if  the  dis- 
placement continue.  It  can  be  usually  palliated,  even  to  such  a 
degree,  sometimes,  that  the  patient  is  perfectly  comfortable  in  the 
recumbent  position,  or  even  while  she  takes  moderate  exercise ; 
but  "  relapses,"  as  Dr.  Gooch  has  observed,  are  frequent  on  the 
least  motion,  sometimes  even  by  walking  across  the  room,  or  by  a 
drive  in  a  carriage.  In  other  cases,  no  palliation  can  be  secured; 
the  patient  becomes  a  martyr  to  constant  and  occasionally  increas- 
ing agony,  involving  the  functions  of  mind  and  body. 

Case. — We  have  lately  taken  charge  of  an  unmarried  lady,  with 
a  retroverted  uterus,  but  who  was  treated  for  "  spinal  neuralgia," 
of  long  duration.  She  was  forced,  a  long  time  since,  to  resort  to 
crutches ;  she  has  now  been  confined  to  her  bed  for  nearly  ten 
months,  but  the  pain,  nausea,  and  vomiting  constantly  increased, 
so  that  for  the  last  month  nothing  was  retained  on  the  stomach 
but  brandy,  and  the  retching  so  constant  and  distressing  as  to 
forbid  sleep  night  or  day.  She  became  greatly  exhausted ;  in  de- 
spite of  the  best  efforts  to  palliate,  from  as  excellent  a  medical 
practitioner  as  our  city  can  afford. 

Such  cases  are  by  no  means  unfrequent.  Ladies  often  suffer 
five,  ten,  fifteen,  twenty  years,  or  even  longer,  under  any  and  every 
treatment,  if  the  displacement  be  permitted  to  remain  unrelieved. 

The  reverse,  according  to  our  observation,  is  also  true,  that  if 
the  displacement  be  completely  relieved,  the  suffering  disappears 
with  the  most  marvellous  rapidity.  The  practical  difficulty  is  the 
perfect  restoration  of  the  displaced  organ.  When,  however,  this 
is  accomplished,  the  relief  to  suffering  follows  very  universally. 
Indeed,  the  mitigation  of  suffering  is,  generally,  in  proportion  to 
the  degree  in  which  the  displacement  has  been  moderated.     In 


348      SYMPTOMS    OF    DISPLACEMENTS    OF    THE    UTERUS. 

the  case  above  mentioned,  upon  the  removal  of  the  displacement, 
the  nausea  and  retching  disappeared  at  once ;  sleep  followed ;  and 
the  ability  to  receive  food,  good  digestion,  increase  of  color,  of 
flesh,  and  of  strength,  succeeded  each  other  with  wonderful  ra- 
pidity. The  alcoholic  potations,  and  the  narcotics,  were  entirely 
abandoned  in  a  short  time,  although  the  retroversion  was  far 
from  being  completely  obviated.  The  whole  of  the  daily  expe- 
rience of  the  author  for  many  years  confirms  this  opinion. 
Numerous  exceptions — apparent  and  real — will  of  course  be 
found ;  but  they,  by  no  means,  invalidate  the  general  proposition. 
Hence,  although  displacements  may  exist  with  more  or  less 
impunity  in  the  strong,  and  in  the  cold  and  phlegmatic  tempera- 
ments, whose  nerves  seldom  vibrate  even  to  powerful  impressions ; 
yet,  in  the  delicate,  luxurious,  sensitive  woman,  whose  mind  and 
body  feelingly  respond  to  every  transient  im.pression,  such  mal- 
positions become  the  source  of  every  kind  and  variety  of  nervous 
irritation.  Even  in  the  non-irritable  woman,  if  morbid  irritation 
exists,  conjoined  with  displacements,  it  will  be  exceedingly  diffi- 
cult to  relieve  the  former,  without  paying  attention  to  the  latter ; 
but,  it  becomes  very  easy  if  the  malposition  be  first  obviated. 
This  proposition,  that  displacements  are  frequently  the  causes, 
original  or  secondary,  of  uterine  suffering,  and  not  mere  nullities, 
will  be  continually  illustrated  in  the  course  of  these  observations. 


DISPLACEMENTS  GENERALLY  CAUSE  INCONVENIENCE. 

The  second  general  deduction  to  be  made  is,  that  in  a  large 
number  of  women  in  civilized  life,  who  have  displacements,  more 
or  less  inconvenience  results,  even  where  the  uterus  is  by  no 
means  very  sensitive.  These  symptoms  of  displaced  uterus  are 
generally  quite  positive ;  some  are  local,  and  relate  to  the  pelvis 
and  its  contents ;  others  are  more  general,  and  disturb  distant  tis- 
sues and  organs. 

Local  Symptoms. — The  most  frequent  and  characteristic  of  the 
local  disturbances  are  sensations  of  fulness,  of  pressure,  and  of 
weight  at  the  lower  portion  of  the  pelvis.  They  are  often  refera- 
ble to  the  rectum,  as  if  it  were  distended,  and  as  if  the  bowels  must 
be  moved,  even  when  the  rectum  is  empty.     This  sensation  has 


DISPLACEMENTS    WITH    SUFFERING.  349 

often  been  attributed  to  internal  lisemorrhoids,  when  they  do  not 
exist.  In  many,  there  is  a  feeling  of  great  relaxation  of  the  peri- 
neum and  vulva,  an  "  open  feeling,"  as  if  all  the  viscera  must  im- 
mediately escape.  Often  there  are  analogous  sensations  about 
the  urethra,  with  frequent  inclination  to  micturate. 

In  the  hypogastrium,  there  is  also  a  sensation  of  emptiness,  of 
sinking,  of  weight,  of  bearing  down,  and  of  inability  to  stand,  or 
even  to  walk. 

There  are  sensations  of  weakness,  of  aching,  or  of  positive 
pain,  in  "the  small  of  the  back" — the  upper  portion  of  the 
sacrum — and  extending  to  the  coccyx,  down  the  limbs,  and 
around  to  the  groin  or  iliac  regions. 

These  and  analogous  disturbances  are  aggravated  by  standing, 
walking,  or  any  muscular  effort,  and  generally  disappear  when 
the  patient  is  at  rest,  especially  in  the  recumbent  position. 

Sometimes  the  uterine  functions  are  not  disturbed;  but  not 
unfrequently  there  is  dysmenorrhoea,  which  is  often  very  severe 
and  at  every  menstrual  period,  even  when  during  the  intervals 
the  patient  feels  comfortable,  and  able  to  take  her  usual  exercise. 
In  other  instances  we  have  leucorrhoea,  menorrhagia,  or  both. 
In  some  cases  these  functional  disturbances  are  almost  the  sole 
indications  of  a  displaced  uterus,  and  remain  indomitable  till  the 
displacement  is  relieved. 

General  Symptoms. — The  general  disturbances  have  reference 
chiefly  to  the  nervous  system.  The  vascular  system  is  not  much 
involved. 

The  most  frequent  of  these  general  symptoms  is  a  sense  of  lan- 
guor, lassitude,  and  "weakness."  It  is  an  effort  to  make  any 
exertion  ;  a  short  walk  produces  great  fatigue.  There  is  a  great 
indisposition  to  rise  in  the  morning,  with  a  strong  inclination  to 
sit  or  lie  down  on  every  occasion.  If  on  a  journey,  such  patients, 
after  making  a  slight  exertion,  often  feel  as  if  it  were  impossible 
to  move  any  further ;  and  they  must  rest  for  some  twelve,  twenty- 
four,  or  forty-eight  hours,  to  recover  strength.  With  this  lassi- 
tude, there  are  often  uneasy  sensations,  not  unfrequently  pain  in 
the  dorsal  or  cervical  portions  of  the  spinal  column.  Sensations 
of  lightness  in  the  head,  and  a  disposition  to  headache  at  all 
times,  are  generally  experienced :  frequently  severe  pain  is  felt 


350      SYMPTOMS    OF    DISPLACEMENTS    OF    THE    UTERUS. 

in  the  temples,  eyes,  face,  top  of  the  head,  and  also  towards  the 
base  of  the  cranium. 

The  mind  is  often  indifferent,  and  cannot  be  interested;  the 
memory  fails ;  and  the  patient's  interest  in  the  common  business 
of  life,  and  in  her  relations  and  friends,  is  much  diminished. 
Sometimes  she  is  peevish,  irritable,  restless,  and  excitable. 

These  miserable  disturbances  are  perfectly  consistent  with  not 
only  good,  but  excellent,  organic  health.  The  patient  may  be 
well  supplied  with  good  blood,  may  have  an  excellent  circulation, 
free  secretions,  perfect  nutrition  and  development.  In  other 
instances,  from  confinement,  loss  of  appetite,  etc.,  there  is  more 
or  less  anaemia,  but  still  no  actual  disturbance  of  the  organic  func- 
tions. Often  the  hands  and  feet  are  cold  and  pallid ;  the  face  and 
head  are  frequently  hot  and  flushed.  These  alternations  of  tem- 
perature are  often  very  rapid,  appearing  and  disappearing  at 
short  intervals ;  but  they  can  always  easily  be  distinguished  from 
fever,  to  which,  indeed,  they  have  but  few  points  of  resemblance. 
The  disposition  to  languor,  to  coldness  or  chilliness,  generally 
occurs  in  the  mornings,  while  the  vascular  excitement  is  usually 
in  the  evenings;  so  that  such  patients,  although  perhaps  most 
miserable  in  the  early  part  of  the  day,  are  often  bright  and 
happy  in  the  evening. 

Conclusions. — That  these  local  and  general  symptoms,  and 
many  others  of  a  similar  character,  are  indeed  the  result  of  a  dis- 
placed uterus,  even  when  there  is  little  or  no  increased  sensi- 
bility of  this  organ,  is  proved  by  the  facts,  that  they  are  often 
coexistent  with  the  displacement ;  that  there  is  generally  no 
other  local  disturbance;  and  especially  that,  the  displacement 
being  removed,  the  symptoms  disappear.  When  this  is  accom- 
plished, the  patient  feels  light,  can  stand  erect,  can  move  with 
ease  and  freedom,  can  take  even  long  walks,  becomes  interested 
in  her  books  and  friends,  is  cheerful  and  amiable,  and  is  pre^ 
pared  for  the  performance  of  the  duties  and  the  enjoyment  of  the 
pleasures  of  life. 


AGGRAVATION    OF    SYMPTOMS.  351 


SYMPTOMS  AGGRAVATED  TF  THE  UTERUS  BE 
SENSITIVE. 

The  third  observation  in  this  process  of  analysis  is,  that  when 
from  displacements  of  the  uterus  alone,  or  from  other  causes, 
physical,  intellectual,  or  moral,  the  uterus  becomes  morbidly 
sensitive,  we  then  have  a  great  aggravation  of  the  above  detailed 
symptoms,  and  a  more  or  less  full  development  of  those  local  and 
genera]  phenomena  of  pelvic  and  cerebro-spinal  irritation,  which, 
have  been  detailed  in,  the  first  part  of  this  work,  as  the  evidences 
of  uterine  and  sacral  irritation.  These,  therefore,  with  all  the 
severe  reflex  influences  on  the  various  organs  of  the  economy,  need 
not  be  repeated.  They  may,  to  be  sure,  exist  in  men  as  well  as  in 
women;  but  in  the  former  they  are  exceedingly  rare,  while  in  the 
latter  they  are  very  frequent.  Although  sometimes,  of  course, 
unconnected  with  displacements,  yet  they  are  so  frequently  coex- 
istent and  inseparable,  as  to  defy  the  best  ordered  and  most  sys 
tematic  treatment  as  long  as  such  displacements  are  allowed  to 
remain ;  but  they  rapidly  vanish  even  under  very  simple  treat- 
ment, when  the  malpositions  are  corrected. 

Practical  Deductions. — l^h.Q  practical  deductions,  as  confirmed 
by  long-continued  experience,  seem  to  the  author  inevitable,  that 
malpositions  of  the  uterus  are  so  intimately  connected  with  all  the 
phenomena  of  irritable  uterus,  as  original  or  aggravating  causes, 
as  to  make  their  removal  generally  absolutely  necessary  for  the 
return  of  the  organ,  and  of  the  cerebro-spinal  system  to  its  nor- 
mal state;  that  dysmenorrhcea,  menorrhagia,  and  leucofrhcea,  the 
pelvic  sufferings,  the  inability  to  walk  or  stand,  the  spinal  and 
cerebral  irritations,  with  all  the  occasional  but  terrible  disturb- 
ances of  the  larynx,  lungs,  heart,  stomach,  liver,  kidneys,  and 
bowels — especially  the  rectum — can  hardly  be  completely  relieved, 
and  sometimes  not  even  palliated,  if  the  displacement  be  per- 
mitted to  remain ;  but,  on  the  contrary,  if  this  be  removed,  re- 
covery will  generally  quickly  follow. 

There  are,  perhaps,  many  cases  of  cerebro-spinal  irritation,  of 
"hysteria,"  as  sucb  complaints  are  usually  named,  in  which  no 
displacement  exists;  and  that  many  possibly  may  be  found,  even 
where  there  is  no  uterine  irritation  of  any  kind — inflammatory 


352      SYMPTOMS    OF    DISPLACEMENTS    OF    THE    UTERUS. 

or  otherwise — no  one  will  deny.  Besides  these  cases,  there  have 
occurred  to  the  author,  and  doubtless  to  others,  those  in  which 
the  displacement  had  been  completely  relieved,  yet  the  local  and 
general  symptoms,  although  palliated,  still  persisted.  This  per- 
sistence is  very  often  due  to  our  ignorance  of  the  sources  of  sacral 
irritation ;  as,  from  pessaries  in  the  vagina,  from  irritable,  enlarged, 
or  displaced  ovaries  or  other  pelvic  tumors,  from  some  state  of 
the  rectum,  of  the  tissues  in  the  region  of  the  sacrum,  or  of  the 
bone  itself.  There  must  be  a  local  irritation  to  disturb  the  nerve 
centres ;  it  is  generally  in  the  pelvis,  although  it  may  exist  in  any 
tissue  or  organ  of  the  body.  A  case  of  the  kind  has  been  detailed 
to  the  author  by  a  "resident  physician"  at  the  Pennsylvania 
Hospital,  where  hysteria  had  evidently  been  excited  by  the  irri- 
tation of  a  diseased  knee-joint.  It  seems  impossible,  at  least  for 
the  author,  to  conceive  of  spinal  or  cerebral  irritation  without  a 
local  cause.  There  must  be  an  irritant  acting  on  the  irritability 
of  a  tissue  to  produce  irritation. 


DIAGNOSIS. 

The  diagnosis  of  displacements  of  the  uterus  cannot  be  satis- 
factorily determined  merely  from  the  symptoms,  however  accu- 
rately studied.  There  are  so  many  morbid  sensations  in  nervous 
women,  so  much  exaggeration  in  their  description  of  their  feel- 
ings, and,  withal,  so  many  other  causes  of  pelvic  irritation,  espe- 
cially perhaps  in  young  females,  that  a  physical  examination 
becomes  positively  necessary  either  to  verify  or  to  contradict 
our  suspicions.  The  same  difficulty  of  forming  a  diagnosis  from 
symptoms  alone,  every  obstetrician  knows,  exists  in  the  case  of 
pregnancy.  The  mere  sensations  of  the  patient  often  deceive 
her  even  to  the  supposed  full  period  of  utero-gestation ;  or  the 
symptoms,  even  when  carefully  examined,  frequently  mislead  the 
practitioner.  Dropsies  and  other  swellings  have  been  mistaken 
for  pregnancy ;  and  on  the  other  hand,  pregnancy  has  often  been 
the  sole  cause  of  disturbance,  when  the  woman  had  been  treated 
for  months  on  account  of  other  developments. 

In  both  cases,  some  approximation  to  the  truth  can  occasionally 
be  made  by  a  careful  analysis  of  the  symptoms ;  but  vaginal  exa- 


SPECIAL    SYMPTOMS.  353 

minations  are  still  more  imperative  to  detect  the  presence  and  to 
determine  the  variety  of  displacement,  than  to  ascertain  the  exist- 
ence of  pregnancy. 

Special  Symptoms. — Anteversmi  of  the  uterus  might  be  anti- 
cipated when,  with  other  intimations,  there  is  a  great  sensation  of 
pressure  in  the  pubic  region,  with  almost  constant  uneasy  sensa- 
tions in  the  bladder,  and  a  frequent  disposition  to  pass  urine, 
which  is  usually  done  without  much  pain  or  difficulty,  and  with 
temporary  relief.  There  is  generally  also  a  sensation  of  fulness 
about  the  vulva.  Similar  disturbance  of  the  functions  of  the 
bladder  exist  frequently,  also,  in  retroversion  of  the  uterus. 

In  Prolajjsiis  uteri,  the  symptoms  of  sacral  irritation  are  trifling, 
or  altogether  absent.  There  is  a  sensation  of  weight  at  the  peri- 
neum or  rectum,  as  if  a  stool  was  demanded,  or  as  if  hgemorrhoids 
Avere  present.  The  patient  often  cannot  bear  to  sit  down,  and 
suffers  while  riding,  especially  over  a  rough  road.  The  character 
of  this  displacement  is  to  be  determined,  however,  rather  by 
negative  than  by  positive  signs,  by  the  absence  of  the  indications 
of  anteversion  or  retroversion. 

The  diagnosis  of  Retroversion  of  the  organ  is  generally  more 
positive.  It  is  usually  indicated  by  decided  symptoms  of  sacral 
irritation ;  pain  in  the  small  of  the  back  ;  uneasiness  in  the  rec- 
tum ;  apparent  and  sometimes  partial  obstruction  to  defecation  ; 
a  flattened  condition  of  the  feeces;  severe  sufferings  while  at 
stool,  in  the  sacrum  and  posterior  perineum,  with  subsequent 
prostration;  long-continued  uneasiness  in  the  bladder,  with  pain- 
ful, often  repeated  efforts  to  urinate  ;  the  necessity,  seemingly 
absolute,  to  continue  these  efforts  for  a  long  time,  or  to  repeat 
them  every  few  minutes ;  inability  often  to  lie  on  one  side  or  the 
other,  and  a  disposition,  in  many  cases,  to  lie  on  the  abdomen. 
Generally,  in  retroversion,  there  are  also  more  decided  symptoms 
of  spinal  and  cerebral  irritation,  of  disturbances  of  the  stomach,, 
heart,  and  lungs,  and  a  more  complete  inability  to  stand  or  walk, 
than  in  the  other  displacements.  Nevertheless,  even  here,  verifi- 
cation by  vaginal  examination,  is  necessary. 

Flexion  of  the  neck  or  body,  also,  can  only  be  established  by  a 
tactile  examination.  "We  may  suspect  it,  however,  in  all  those 
displacements  where  there  is  the  complication  of  dysmenorrhoea,. 
23 


354:      SYMPTOMS    OF    DISPLACEMENTS    OF    THE    UTERUS. 

which  SO  often  depends  on  the  obstruction  arising  from  the  bend- 
iug  of  the  neck.' 

'  The  subject  of  flexions  of  the  uterus  has  attracted  very  little  attention  until 
within  the  last  few  years,  and  its  proper  role,  or  relative  value  in  uterine  com- 
plaints, has  not  yet  been  fixed.  Thus,  the  distinguished  German  teacher  Scan- 
zoni,  regards  flexions  as  of  little  importance  ;  but,  at  the  same  time,  as  quite  incur- 
able, whether  by  medicinal  or  surgical  measures.  Dr.  West  does  not  materially 
difler  from  this  opinion.  Mr.  Tilt  does  not  refer  dysmenorrhcea  nor  sterility  to 
flexions.  M.  Goupil,  while  acknowledging  the  existence  of  flexions,  ascribes  the 
supposed  consequences  to  congestion  and  inflammations,  and  treats  liis  patients 
not  for  flexions  or  displacement,  but  for  such  congestion.  Dr.  Wright  attributes 
bad  symptoms,  on  the  contrary,  to  displacements,  whether  with  or  without  flexion  ; 
insisting,  therefore,  that  a  reposition  is  absolutely  necessary,  as  much  so  as  the 
reduction  of  a  bone  which  has  been  thrown  out  of  its  socket,  instead  of  trusting 
to  antiphlogistics. 

These  citations  are  sufficient  to  exhibit  the  discrepancy  of  opinion  on  the  sub- 
ject. Some  authors  affirm  also  that  flexions  seldom  occur  in  the  virgin  condition, 
being  chiefly  a  consequence  of  the  parturient  state ;  others,  on  the  contrary,  state 
that  it  is  seldom  found  in  women  who  have  had  children.  Dr.  Wright  inclines  to 
the  opinion  that  flexion  cannot  occur  in  a  healthy  uterus ;  its  tissues  are  too  firm. 
He  supposes,  therefore,  that  there  is  always  a  predisposition  arising  from  a  morbid 
laxity  or  softness  of  this  body  ;  while  some  authors  think  that  there  must  be  a 
congenital  deformity,  or,  at  any  rate,  a  degeneration  of  tissue  at  the  point  of 
flexion. 

The  causes  of  flexion  are,  therefore,  regarded  as  exceedingly  obscure.  To  us 
this  seems  very  surprising,  and  also  the  idea  too  frequently  inculcated  that  flexion 
is  a  distinct  or  peculiar  kind  of  displacement,  instead  of  regarding  it  as  a  mere 
addition  or  complication  to  an  existing  malposition  of  the  uterus.  The  view  as 
presented  in  the  text,  and  which  has  guided  the  author's  practice  for  very  many 
years — and,  as  he  thinks,  with  great  success — is,  that  the  essential  cause  is  pres- 
sure from  above.  Under  the  steady  influence  of  a  superincumbent  weight,  pro- 
lapsus of  the  uterus  ensues,  the  os  impinges  against  the  posterior  wall  of  the 
vagina,  preventing  further  descent,  while  day  after  day  the  pressure  is  being 
exerted  so  constantly  that  the  flrm  tissues  of  the  cervix  gradually  yield,  so  that 
not  only  flexion  ensues,  but  various  deformities  even  are  produced  as  described 
in  the  text.  Hence,  flexions  of  the  cervix  are  very  common  in  the  early  stages  of 
pregnancy,  and  very  often  in  the  virgin,  being  with  her  one  of  the  most  frequent 
causes  of  dysmenorrhcea ;  or,  if  marriage  has  ensued,  preventing  conception.  In 
parturient  women  it  is  not  so  common.  Flexions,  therefore,  are  a  frequent  and 
by  no  means  an  unimportant  complication  of  displacement.  The  proof  is  based 
on  the  fact  constantly  observed  in  the  practice  of  the  author,  that  such  flexions 
are  not  incurable,  as  so  frequently  asserted  by  high  authorities  ;  that  they  can  be 
easily  rectified  by  the  measures  already  detailed;  and  that  in  a  large  number  of 
oases  the  bad  consequences,  especially  dysmenorrhcea  and  sterility,  will  be  ob- 
viated. We  are  the  more  anxious  to  press  this  subject  upon  professional  atten- 
tion, not  merely  that  we  feel  confident  that  pressure  is  the  real  source  of  mischief 
which  can  be  readily  relieved,  but  because  so  many  influential  gynecologists  de- 
clare that  flexions  are  innocuous,  or  that  they  are  incurable,  while  the  bolder  and 


SPECIAL    SYMPTOMS.  355 

The  symptoms  of  Procidentia,  as  described  by  the  patient, 
would  seem  generally  to  be  very  positive;  but,  certainly,  no 
practitioner  would  trust,  in  pronouncing  an  opinion,  to  any  such 
description,  without  having  confirmed  it  by  his  own  senses. 
There  are  many  sources  of  deception  to  the  woman,  or  to  the 
uninstructed,  as,  for  example,  the  partial  or  complete  prolapsus 
or  procidentia  of  the  vagina,  the  uterus  being  within  the  vulva; 
the  descent  of  a  portion  of  the  bladder  or  rectum ;  the  swelling 
of  the  hard  or  "prostatic"  portion  of  the  urethra;  the  formation 
of  tumors  in  this  tissue,  or  in  the  sides  of  the  vulva,  the  vagina, 
or  the  uterus  itself,  as  in  cases  of  polypi,  which  protrude  exter- 
nally ;  or  more  rarely,  it  may  be  not  a  simple  case  of  procidentia, 
but  complicated  with  a  previous  inversion  of  the  organ. 

In  all  cases  of  procidentia  of  the  uterus,  the  bladder  is  neces- 
sarily disturbed  in  its  functions.  There  is  often  difficulty  in 
urinating ;  sometimes  it  is  so  great  that  no  excretion  can  occur 
until  the  whole  tumor  be  restored  within  the  vulva. 

As  regards  the  nervous  symptoms,  it  is  perhaps  inexplicable, 
but  in  accordance  with  the  uniform  experience  of  the  author, 
that  they  are  comparatively  very  moderate.  The  uterus  itself 
does  not  become  very  irritable  or  sensitive,  and  the  sympathetic 
affections  of  the  pelvic  nerves,  of  the  spinal  marrow,  and  of  the 
brain  are  often  trifling,  and  sometimes  hardly  recognizable.  The 
explanation  is  not  very  evident,  but  may  possibly  be  referable  to 
the  fact  that  when  the  uterus  is  extruded  it  is  no  longer  under 
the  influence  of  the  abdominal  muscles,  is  no  longer  impinging 

more  decided  spirits  of  the  profession  are  exercising  their  science  and  manual 
dexterity  in  devising  and  executing  surgical  operations  for  the  removal  of  obstruc- 
tions in  the  cervical  canal,  or  of  supposed  deformities  in  the  neck  of  the  uterus. 
We  do  believe  that  a  large  proportion  of  the  supposed  strictures  are  dependent 
upon  flexions,  and,  with  few  exceptions,  there  are  no  deformities  of  the  cervix 
which  will  not,  with  slight  assistance,  disappear  gradually  after  pressure  from 
these  tissues  has  been  removed.  Hence  it  results  that  the  frequent  employment 
of  the  uterotome,  with  all  its  proposed  modifications  of  the  scissors  and  tlie  ampu- 
tating scalpel,  is  not  only  tedious,  painful,  and  dangerous,  but  unscientific  and 
unnecessary. 

These  observations  apply  not  simply  to  "prolapsus  with  flexion,"  but  with 
equal,  indeed  with  still  more  force  to  anteflexion  and  retroflexion  of  the  uterus. 
The  cause  of  such  accidents  not  having  been  investigated,  the  treatment  has  been 
conducted  upon  improper  principles,  and  has  proved  often  ineffectual,  and,  in 
some  instances,  fatal.  This  is  true  even  as  regards  the  "intra-uterine  stem 
pessary." 


356      SYMPTOMS    OF    DISPLACEMENTS    OF    THE    UTERUS. 

against  solid  substances,  and  cannot  directly  irritate  the  pelvic 
nerves,  but  hangs  in  a  soft  cavity  formed  by  the  inversion  of  the 
vagina. 

Vaginal  Examinations  must  be  made  in  all  cases  of  sup- 
posed displacement,  in  order  that  the  diagnosis  may  be  accurately 
established,  and  a  rational  treatment  be  instituted, 

A  decided  Procidentia  is  easily  detected.  The  whole  organ, 
and  sometimes  also  its  tubes  and  round  ligaments,  can  readily 
be  felt,  and  its  form  and  size  recognized  through  its  vaginal 
covering.  A  finger  in  the  rectum,  or  a  curved  sound  in  the 
bladder,  will  indicate  that  one  or  both  of  these  viscera,  occasion- 
ally, are  partially  drawn  down  with  the  uterus.  The  os  uteri 
can  readily  be  seen  and  felt,  as  well  as  the  insertion  of  the  vagina 
near  its  margin. 

Very  generally,  in  procidentia  of  a  chronic  character,  the  whole 
tissue  of  the  mucous  membrane  of  the  vagina  is  altered  by  inflam- 
mation, brought  on  by  the  innumerable  sources  of  irritation  due 
to  its  exposure,  out  of  the  vulva  between  the  limbs  of  the  patient. 
Hence  result  patches  of  inflammation  ;  mucoid  and  purulent,  and 
even  bloody  discharges  from  this  surface ;  hence  also  ulcerations, 
indurations,  and,  it  may  be,  gangrene,  and  sphacelus.  Sometimes, 
after  long  exposure,  the  peculiar  soft  character  of  the  vagina  is 
so  altered,  as  to  resemble  in  appearance  and  to  the  touch,  the 
character  of  the  dermoid  tissue,  with  its  epithelial  scales.  Cases 
have  been  recorded  where,  in  consequence  of  inflammation,  that 
portion  of  the  peritoneal  sac  containing  the  uterus  and  its  ap- 
pendages had  been  obliterated  by  adhesions,  thus  shutting  the 
uterus  out  from  the  general  cavity  of  the  peritoneum,  and  ren- 
dering reduction  difficult,  if  not  inpossible. 

The  diagnosis,  therefore,  of  procidentia  uteri  can  be  easily 
determined  by  an  ocular  and  digital  examination.  It  can  thus 
be  readily  distinguished  from  a  prolapsus  of  the  vagina,  of  the 
bladder,  or  of  the  rectum,  from  inversion  of  the  uterus,  from 
polypi  of  the  womb,  and  from  steatomatous,  fibrous,  or  other 
tumors  projecting  from  the  vulva. 

In  the  other  m,al-positions  of  the  womb  even  less  reliance  should 
be  placed  on  the  symptoms.  The  innumerable  varieties  of  morbid 
sensation  may  arise  from  so  many  sources,  that  no  careful  patho- 
logist would  venture  to  give  a  positive  opinion,  from  the  history 


VAGINAL    EXAMINATIONS.  357 

of  the  case,  as  to  the  existence  of  displacement,  and  of  course  still 
less  as  to  the  kind  of  displacement.  However  frequently,  or  even 
constantly,  these  nervous  or  hysterical  sensations  are  associated 
with  displacements,  they  may  exist  without  any  alteration  in  the 
position  of  the  organ,  and,  as  has  been  observed,  may  remain, 
even  when  they  have  been  coincident  with  a  mal-position,  after 
such  mal-position  has  been  rectified.  Nevertheless,  they  are  so 
intimately  connected  as  cause  and  effect,  that,  in  all  protracted 
nervous  complaints,  it  will  be  advisable  to  ascertain,  by  examina- 
tion, the  position  as  well  as  other  morbid  states  of  the  uterus. 
Such  examination,  and  the  treatment  which  may  be  founded  on 
its  results,  are  often,  indeed,  essential  for  the  recovery  of  the 
patient — a  "  sine  qua  non." 

By  the  "  touch"  the  instructed  anatomist  and  the  experienced 
practitioner  will  have  no  real  difficulty  in  determining  not  merely 
the  existence  of  a  displacement,  but  also  its  character  and  its 
various  complications.  Nevertheless,  so  little  attention  has  been 
directed  to  this  subject;  so  many  egregious  mistakes  have  been 
and  are  so  constantly  made  as  to  what  is  or  what  is  not  the  natu- 
ral position  of  the  uterus;  and,  in  some  cases,  there  are  so  many 
real  difl&culties,  that  it  becomes  requisite  to  illustrate  the  manner 
in  which  such  examinations  should  be  made,  and  some  of  the 
difficulties  which  may  exist. 

Anatomical  Facts. — Let  reference  be  made,  therefore,  to  the 
anatomical  facts  already  enumerated  in  the  chapter  on  the  natural 
position  of  the  uterus :  especially  the  obliquity  of  the  pelvis,  as 
regards  the  axis  of  the  body ;  the  parallelism  of  the  axis  of  the 
uterus  with  that  of  the  superior  strait  of  the  pelvis;  the  conse- 
quent oblique  position  of  this  organ  as  regards  the  axis  of  the 
body;  the  coccygeal  region  constituting  the  floor  or  bottom  of 
the  pelvis,  while  the  orifice  of  the  vagina  is  at  the  anterior  por- 
tion ;  the  axis  of  the  vagina  forming  an  acute  angle  with  the  axis 
of  the  uterus,  and  running  from  below  the  symphysis  pubis 
towards  the  lower  part  of  the  sacrum ;  the  uterus  a  movable 
organ,  and  supported  in  its  central  position  in  the  cavity  of  the 
pelvis,  not  by  the  vagina,  but  by  its  ligaments,  which,  in  their 
natural  state,  as  to  length  and  tonicity,  assisted  by  the  attach- 
ments and  reflections  of  the  pelvic  fascia,  and  by  the  position  and 
pressure  of  the  small  intestines  and  the  bladder,  are  fully  able  to 
maintain  it  in  situ,  and  yet  allow  its  pendulum-like  motion  in  the 


358      SYMPTOMS    OF    DISPLACEMENTS    OF    THE    UTERUS, 

cavity  of  the  pelvis.  A  practical  acquaintance  witli  these  facts 
will  render  the  diagnosis  very  easy,  with  perhaps  a  few  exceptions. 
Mode  of  making  the  Examination. — Undoubtedly  the  best  posi- 
tion of  the  woman,  for  these  examinations  in  cases  of  displacements 
of  the  uterus  and  tumors  of  the  abdomen,  is  directly  on  the  back, 
with  the  knees  drawn  up  and  separated,  the  pelvis  approximating 
the  edge  of  the  bed,  and  a  little  elevated,  with  the  shoulders  un- 
supported by  a  pillow.  Thus  the  practitioner  can  easily  make 
an  external  as  well  as  an  internal  examination. 

If  an  examination  be  made,  as  is  too  often  done,  with  the 
patient  upon  the  side,  the  intestines  will  gravitate  to  that  side  of 
the  body,  the  uterus  will  usually  rise  higher  in  the  pelvis,  and 
incline  laterally,  so  that  its  mal  position  will  often  not  be  appa- 
rent. Occasionally,  however,  this  method  is  important  to  examine 
the  upper  parts  of  the  rectum,  the  vagina,  etc.  The  erect  posture 
may,  in  a  few  instances,  be  advantageous,  especially  in  those  cases 
where  the  organ  is  displaced  only  when  the  woman  is  erect.  In 
this  position,  the  exploration  is  inconvenient,  for  the  practitioner 
is  necessarily  much  restricted,  and  cannot,  from  the  tension  of  the 
abdominal  muscles,  make  any  satisfactory  investigation  through 
the  parietes  of  the  abdomen.  It  is  always  desirable  that  the  blad- 
der and  the  rectum  should  have  been  previously  emptied. 

If  the  j)arts  be  in  situ  naturally  the  index  finger,  after  entering 
the  vagina,  should  come  in  contact  with  the  anterior  surface  of  the 
uterus,  felt  distinctly  through  the  parietes  of  the  vagina  and  blad- 
der. The  OS  uteri  will  be  found  below  the  level  (the  patient 
being  on  her  back)  of  the  os  vagina3,  and  pointing  towards  the 
region  of  the  coccyx,  and  making  no  firm  pressure  on  the 
posterior  wall  of  the  vagina.  The  cervix  and  body  should  be 
perfectly  straight,  free  from  flexion.  If  the  woman  be  not  cor- 
pulent, the  fundus  of  the  uterus  may  with  some  attention  be 
recognized  by  the  fingers  of  the  other  hand  placed  on  the  hypo- 
gastric region,  when  the  uterus  is  slightly  elevated  by  the  finger 
in  the  vagina. 
f  In  Prolapsus  uteri,  as  already  defined,  the  chief  indications 
[  arise  from  the  position  and  state  of  the  os  and  cervix  uteri.  The 
body  may  be  found  sometimes  very  near  the  pubis ;  sometimes, 
however,  there  is  a  slight  inclination  of  its  axis,  so  that  the  fun- 
dus approximates  the  sacrum,  though  it  has  not  fallen  below  the 
promontory ;  but  the  os  impinges  firmly  upon  the  posterior  wall 


MODE    OF    MAKING    EXAMINATIONS.  359 

of  the  vagina  and  upon  the  rectum.  If  it  be  a  chronic  case,  the 
form  of  the  os  uteri  is  often  altered ;  the  anterior  lip  usually 
projects,  and  sometimes  is  tumid,  while  the  posterior  lip  is  flat- 
tened ;  so  that  together  they  closely  resemble  the  mouth  of  a  hog, 
the  orifice  appearing  to  be  nearer  the  posterior  than  the  anterior 
surface^ 

When  there  is  flexion^  it  varies  much  as  to  degree.  If  mode- 
rate, a  bend  is  noticed  by  passing  the  finger  along  the  anterior 
surface  of  the  cervix,  but  the  os  is  still  in  contact  with  the  peri- 
neum. In  decided  cases,  the  os  is  found  pointing  towards  the 
orifice  of  the  vagina ;  the  end  of  the  finger,  passing  directly  in 
the  axis  of  the  vagina,  meets  the  os  uteri.  The  first  idea  would 
be,  that  the  uterus  was  retroverted ;  for,  if  the  organ  were 
straight,  the  fundus  would  then  necessarily  be  towards  the  sac- 
rum; but  in  these  cases  of  flexion,  the  anterior  surface  of  the 
organ  will  be  detected  behind  the  bladder  and  the  pubis.  It  is 
a  case  of  prolapsus  with  flexion.  It  might  be  termed  a  simple 
case  of  flexion. 

Flexion  very  generally  exists  in  the  cervix  uteri,  about  its 
middle  or  upper  third;  occasionally  at  the  internal  os;  some- 
times in  the  lower  portion ;  very  seldom  in  the  body  of  the 
uterus,  although  such  cases  are  met  with.  The  degree  of  flexion 
varies  from  slight  curvature  to  that  where  the  cervix  bends  at  an 

acute  angle.     Dr. states  a  case  where  the  curvature  of  the 

lower  extremity  was  so  great  that  the  os  externum  appeared  to 
be  upon  the  anterior  surface  of  the  neck.  ^When  flexions  exist 
for  a  long  time,  thinness  and  even  fatty  degeneration  of  the 
tissues  are  said  to  occur  on  the  concave  surface.  J)  Hence,  care 
should  be  always  taken  not  to  penetrate  these  degenerated  tissues, 
when  an  examination  is  made  by  means  of  a  sound. 

In  Anteversion,  which  is  comparatively  a  rare  displacement,  the 
fundus  will  be  found  opposite  to  the  body  of  the  pubis,  while  the 
index  finger  must  be  extended  along  the  anterior  surface  of  the  v 
uterus,  deep  into  the  vagina,  so  as  to  reach  the  extremity  of  the 
cervix,  pointing  towards  the  hollow  of  the  sacrum,  far  from  the 
OS  coccygis.  To  effect  this  the  patient,  particularly  if  a  virgin, 
niust  often  be  placed  on  the  side,  especially  if  it  be  desirable  to  • 
examine  the  lips  and  the  mouth  of  the  womb. 

Very  generally,  however,  in  anteversion  there  is  also  flexion, 
varying,  of  course,  as  to  degree.     Owing  to  this,  the  cervix  and 


c 


360      SYMPTOMS    OF    DISPLACEMENTS    OF    THE    UTERUS. 

OS  uteri  are  often  found  in  their  natural  position,  towards  the 
coccyx ;  while  the  fundus  is  opposite  to  the  pubis.  In  similar 
positions  of  the  body  of  the  uterus,  the  neck  is  sometimes  so  bent, 
that  the  os  approximates  the  perineum,  and  even  may  be  almost 
parallel  with  the  ostium  vaginte.  The  only  mode  of  diagnosis, 
therefore,  between  such  cases  and  those  of  prolapsus  of  the  uterus, 
is  by  careful  attention  to  the  position  of  the  fundus. 

i'ln  Retroversion  of  the  uterus,  when  complete,  the  finger  will 
detect  a  tumor  through  the  upper  portion  of  the  vagina,  behind 
the  cervix,  resting  upon  the  rectum.^  That  this  is  the  uterus, 
may  be  rendered  evident,  by  carefully  tracing  the  continuity  of 
tissue  to  the  os ;  this  is  found  pointing  towards  the  body  of  the 
pubis,  but  not  close  to  it,  for  in  the  normal  state,  the  organ  is 
too  short  to  extend  from  the  coccyx  to  the  pubis.  (  The  diag- 
nosis is  strengthened  by  pressing  against  the  bladder,  in  front  of 
the  OS  uteri,  and  finding  no  firm  resistance ;  and  by  examining 
per  rectum,  where  a  tumor  will  be  distinctly  felt  through  the 
anterior  walls  of  this  tube,  of  the  regular  uterine  formp  This 
exploration  is  rendered  more  complete  if  the  index  finger  of  the 
other  hand  be  at  the  same  time  inserted  into  the  vagina,  so  that 
the  continuity  of  tissue  between  the  cervix  and  body  can  be 
more  fully  determined.^  Very  generally  this  rectal  examination 
gives  much  pain,  indeed,  often  much  more  than  the  vaginal; 
sometimes  it  is  almost  intolerable,  the  patient  screaming  when 
the  least  pressure  is  made  on  the  tumor.  This  will  confirm  the 
idea  that  the  uterus  constitutes  the  tumor,  as  new  or  adventitious 
growths  have  seldom  any  great  sensibility.  The  diagnosis,  if  still 
doubtful,  may  be  positively  confirmed  by  passing  a  curved  uterine 
probe,  with  its  convexity  towards  the  pubis,  into  the  cavity  of 
the  neck  and  body  of  the  uterus;  a  finger  in  the  rectum  will  re- 
cognize without  difiiculty,  the  point  of  the  probe,  through  the 
parietes  of  the  uterus  and  rectum.  Care,  however,  is  always 
demanded  in  order  to  avoid  mistakes.  A  collection  of  fasces  in 
the  upper  part  of  the  rectum,  an  ovarian  tumor,  an  abnormal 
uterine  tumor,  an  enlarged  lymphatic  gland,  a  fibrous  or  other 
heterologous  formation  in  the  pelvis,  an  osseous  enlargement,  a 
scirrhous  or  cancerous  degeneration  of  the  rectum,  have  all  been 
mistaken  for  the  fundus  or  bod}"-  of  the  uterus. 

In  all  cases  in  which  the  fundus  is  not  displaced,  the  uterine 
surface  can  be  recognized  anteriorly,  behind  the  bladder,  and  the 


EXAMINATION    OF    RETKO VERSION.  361 

point  of  the  uterine  probe  now  introduced  with  the  concavity 
toward  the  pubis  will  be  felt,  if  the  patient  be  not  too  corpulent, 
not  through  the  rectum,  but  through  the  parietes  of  the  abdomen 
and  uterus,  in  the  hypogastric  region.  A  case  may  illustrate  this 
fact. 

Case. — Our  unbiassed  opinion  was  requested  in  the  case  of  the 
wife  of  an  officer  in  the  army,  in  which  two  distinguished  accouch- 
eurs had  given  very  positive  declarations  as  to  the  condition  of 
the  pelvic  contents.  One  stated  that  he  was  fully  convinced  that 
the  uterus  was  in  situ  naturali^  and  that  an  enlarged  ovary  had 
fallen  behind  the  uterus,  namely,  between  it  and  the  rectum.  The 
other  was  even  more  positive  that  it  was  a  case  of  retroverted 
uterus  with  flexion,  and  that  there  was  no  unnatural  development 
in  the  pelvis;  in  order  that  there  might  be  no  misunderstanding, 
he  made  a  drawing  to  exhibit  his  views  of  the  nature  and  charac- 
ter of  the  affection.  The  lady  was  about  thirty  years  of  age,  had 
been  married,  but  had  never  become  pregnant.  She  had  suffered 
much  from  nervous  affections,  which  frequently  amounted  even 
to  violent  spasms.  After  a  careful  investigation,  we  were  forced 
to  conclude  that  it  was  a  case  of  anteflexion  of  the  uterus,  with  a 
fibrous  tumor  developed  on  its  posterior  wall.  Our  reasons  for 
this  opinion  were — a  tumor  could  be  felt  posteriorly,  and  one 
also  anteriorly  through  the  walls  of  the  bladder ;  a  finger  in  the 
rectum  recognized  a  hard  swelling,  and  a  sound  in  the  bladder 
impinged  against  a  firm  body ;  the  uterus  and  the  tumor  poste- 
riorly were  continuous ;  no  distinct  sulcus  could  be  felt  between 
the  organ  and  the  tumor,  as  would  probably  be  the  case  if  the 
tumor  was  ovarian,  and  besides,  it  was  movable  with  the  organ, 
the  whole  seeming  to  form  one  mass.  The  decisive  mode  of 
diagnosis,  however,  the  "  experimentum  crucis,"  was  made  by 
passing  the  probe  into  the  uterus  with  its  concavity  towards  the 
pubis ;  its  point  could  then  be  distinctly  felt  behind  the  pubis  in 
the  hypogastric  region,  while  a  finger  in  the  rectum  still  recog- 
nized the  posterior  tumor. 

The  diagnosis  in  cases  o^  partial  retroversion  of  the  organ  is  often 
very  difl&cult,  and  will  in  many  instances  prove  incorrect,  unless 
the  examination  has  been  very  carefully  conducted.  In  partial 
retroversion  the  fundus,  in  accordance  with  the  definition  given 
above,  may  be  found  pointing  to  any  portion  of  the  sacrum  below 


362      SYMPTOMS    OF    DISPLACEMENTS    OF    THE    UTERUS. 

the  promontory.  Sometimes,  therefore,  the  axis  of  the  uterus  is 
but  slightly  oblique,  differing  very  little  from  its  direction  in  pro- 
lapsus. In  other  cases,  it  corresponds  with  the  axis  of  the  infe- 
rior strait  of  the  pelvis,  and  in  others  even  to  that  of  the  vagina. 
"When  the  os  uteri  is  low  down  in  the  vagina,  or  when  the  uterus 
from  any  cause,  as  pregnancy,  is  enlarged,  the  diagnosis  is  com- 
paratively easy,  for  the  finger  per  vaginam  or  per  rectum  may 
recognize  the  posterior  surface  of  the  uterus,  while  the  anterior 
cannot,  in  any  way  be  felt.  (But  many  cases  will  be  met  with  in 
an  extensive  practice,  especially  among  virgins,  or  those  married 
women  who  have  never  been  pregnant,  where  the  vagina  is  long 
and  its  walls  dense,  and  where  the  os  uteri  is  so  high  up  as  to 
require  the  whole  length  of  the  index  finger  to  reach  it ;  in  these, 
the  diagnosis  of  the  existence  or  non-existence  of  a  partial  retro- 
version becomes  exceedingly  difl&cult.) 

Case. — Some  fifteen  years  ago,  a  young  lady,  of  excellent  health 
and  a  good  constitution,  was  married  in  Virginia.  Up  to  this  time, 
with  the  exception  of  some  suffering  at  her  menstrual  periods,  she 
had  no  indication  of  pelvic  disease,  could  walk,  and  ride  on  horse- 
back ad  libitum.  Not  many  weeks  after  marriage  the  symptoms 
of  irritable  uterus  were  developed,  her  dysmenorrhoea  became  in- 
tense, and  then  followed  irritations  about  the  bladder  and  rectum, 
inability  to  walk  with  comfort,  etc.  The  usual  palliative  treatment 
was  adopted ;  but  the  symptoms  gradually  became  more  intense. 
She  came  to  Philadelphia,  and  applied  to  an  eminent  practitioner, 
who  offered  no  decided  opinion,  but,  after  a  few  visits,  directed  a 
course  of  medicines  and  sent  her  home,  with  a  favorable  progno- 
sis. Nearly  a  year  after,  she  returned,  and  consulted  another 
experienced  physician.  At  this  time  she  had  become  confined  to 
her  bed ;  she  was  very  pallid,  although  still  fleshy,  and  was  ex- 
cessively nervous,  mentally  and  corporeally;  she  had  frequent 
attacks  of  menorrhagia,  and  experienced  great  trouble  on  urinat- 
ing, while  defecation  was  attended  with  the  most  agonizing  suf- 
fering at  the  time,  and  followed  by  the  greatest  prostration  for 
hours.  She  constantly  affirmed  that  martyrdom  would  be  pre- 
ferable to  the  pain  excited  by  the  opening  of  the  bowels.  Her 
new  physician  treated  her,  for  some  six  months,  for  fissure  of  the 
anus  and  for  nervous  diseases,  with  all  the  assiduity  and  skill 
imaginable.  She  was  not  benefited,  and  was  conveyed  home  in 
the  spring ;  but,  when  the  autumn  came,  with  the  symptoms  rather 


CASE    OF    PARTIAL    RETROVERSION".  363 

aggravated  than  otherwise,  she  was  brought  to  our  care.  A  vagi- 
nal or  rectal  examination  gave  her  intense  pain,  as  these  passages 
and  their  orifices  had  become  excessively  sensitive.  The  vagina 
was  exceedingly  long  and  narrow,  and  would  sometimes  spasmo- 
dically contract  on  a  finger  or  an  instrument  with  great  force.  The 
OS  uteri  was  found  small,  excessively  sensitive,  and  pointing  to  the 
OS  vaginas,  but  so  high  up  as  not  to  be  easily  reached,  especially 
as  the  patient  was  by  no  means  emaciated,  notwithstanding  her 
prolonged  suffering.  No  other  portion  of  the  uterus  was  to  be 
felt,  either  anteriorly  through  the  bladder,  or  posteriorly  through 
the  rectum.  No  swelling  or  tumor  could  be  recognized  in  the 
pelvis,  and,  by  an  external  examination,  no  indication  of  unna- 
tural development  in  the  hypogastric  or  iliac  regions  could  be 
found.  The  logical  inferences  were,  that  there  existed  an  ex- 
cessively irritable  condition  of  all  the  pelvic  organs;  that  the 
uterus  was  of  a  small  size ;  that  its  axis  was  coincident  with  that 
of  the  vagina ;  that  its  fundus  was  pointing  towards  the  hollow 
of  the  sacrum  and  resting  upon  the  sacral  portion  of  the  rectum ; 
that  the  pain  excited  by  the  passage  of  the  ftBceg  was  dependent 
on  the  pressure  thus  necessarily  made  upon  the  sensitive  uterus; 
that  this  irritable  and  displaced  condition  of  the  organ  was  the 
"  radix  malorum,"  the  true  source  of  the  nervous  distress  of  this 
otherwise  healthy  young  woman,  who,  with  all  the  appliances  for 
a  happy  and  useful  life,  had  been  prostrated  by  unremitting  suf- 
fering for  years.  She  was  accordingly  treated  immediately  for 
displacement  of  the  uterus.  Much  trouble  was-  of  course  expe- 
rienced, but  soon  her  symptoms  ameliorated ;  in  a  few  weeks  she 
was  moving  about  again,  and  within  four  months  was  able  to 
attend  some  large  parties  with  much  pleasure,  and  returned  home, 
ready  to  resume  the  ordinary  avocations  of  life.  Since  then,  we 
have  seen  her  several  times,  and  still  oftener  have  heard  of  her 
welfare.  She  has  never  had  any  return  of  her  severe  complaints, 
and  has  become  a  very  useful  and  ornamental  member  of  society. 

The  diagnosis  in  all  such  cases  of  partial  retroversion  will  be 
facilitated  by  the  use  of  the  uterine  probe ;  it  should,  however, 
be  straightened,  for  if  the  attempt  be  made  to  pass  it  while  bent, 
it  either  could  not  be  introduced,  or  would  rectify  the  uterus  by 
the  very  act  of  introduction. 

The  diagnosis  in  cases  of  retroversion  becomes  complicated 
when  there  is  a  bending  of  the  cervix  or  body  of  the  uterus. 


364      SYMPTOMS    OF    DISPLACEMENTS    OF    THE    UTERUS. 

Perhaps  still  more  care  is  required  in  these  cases  of  imrtial 
retroflexion  of  the  uterus.  A  vaginal  examination  proves  the 
OS  and  cervix  to  be  in  a  natural  position,  for  example,  and  the 
practitioner  may  hastily  conclude  that  there  is  no  displacement ; 
while  a  little  more  careful  examination,  by  the  finger  or  by  the 
probe,  would  reveal  the  important  fact  that  the  fundus  rested  in 
the  hollow  of  the  sacrum.  In  other  cases,  the  os  will  be  found  in 
the  direction  of  the  axis  of  the  vagina,  while  the  fundus  is  low 
down  upon  the  coccyx,  or  even  on  the  perineum. 

These  facts  exemplify  the  necessity  of  careful  and  minute  exa- 
mination in  all  cases  of  suspected  displacement  of  this  important 
organ  of  the  female  economy. 


IMPORTANCE  OF  DISPLACEMENTS. 

The  importance  or  non-importance  of  these  displacements  of 
the  uterus  is  by  no  means  a  settled  point.  Extreme  opinions  are 
entertained  by  ^nany.  Certain  it  is,  that  deviations  often  exist 
to  a  great  extent,  with  no  apparent  disturbance  of  the  system; 
and  certainly,  on  the  other  hand,  the  most  severe  forms  of  nerv- 
ous irritation,  cerebral  and  spinal,  have  been  rapidly  relieved  by 
those  mechanical  means  which  have  been  effectual  in  rectifying 
the  position  of  the  uterus. 

This  paradox  seems  to  depend  on  the  peculiar  temperament  of 
the  patients,  'and  the  various  moral  and  physical  excitements  to 
which  they  have  been  exposed.  In  many  instances,  girls,  having 
few  symptoms  of  displaced  uterus,  become,  after  marriage,  mar- 
tyrs to  nervous  affections.  In  others,  the  development  of  nervous 
symptoms  can  be  traced  to  a  long  walk,  a  fatiguing  dance,  or  a 
violent  strain,  as  in  vomiting,  defecation,  coughing,  jumping,  etc. 
Or,  the  whole  nervous  system  becomes  preternaturally  sensitive 
from  anxiety  of  mind,  disappointments  in  life,  or  great  fatigue, 
exhaustion,  etc. 

In  all  such  cases,  the  displacement  becomes  more  and  more  a 
cause  of  mischief,  aggravating  and  maintaining  the  nervous  affec- 
tions, in  opposition  to  the  best  devised  remedial  measures.  Ee- 
lieve  the  displacement,  and  these  patients  will  often  recover 
entirely  by  a  persistence  in  the  same  course  of  remedies  which 
had  before  proved  ineffectual,  or  sometimes  even  by  mere  hygie- 


PROGNOSIS.  365 

nic  attentions.  The  argument  is  not  invalidated  by  the  acknow- 
ledged fact,  that  such  hysterical  affections,  of  a  severe  character, 
will  sometimes  continue  after  the  displacement  has  been  relieved, 
and  are,  not  unfrequently,  excited  originally  without  any  accom- 
panying displacement.  These  constitute  but  the  exceptions  to 
the  rule,  that  displacements  are  usually  connected  with  nervous 
excitements  in  the  female  econom3^ 

There  can  be  no  doubt  that  there  are  various  other  causes  of 
hysteria,  especially  when  the  excitement  is  acute  and  transitorj^, 
such  as  mental  and  moral  affections,  sexual  feelings,  irritations  in 
the  teeth,  stomach,  bowels,  etc.,  and  even  severe  pain  from  any'^ 
accidental  cause;  but  in  tedious  chronic  cases,  the  principle  is 
true,  that   neuralgic,  nervous  excitations,   spasms,  convulsions,  i 
and  the  whole  train  of  morbid  sensations;  are  dependent  on  some 
local  cause,  the  removal  of  which  is  all-important  for  recovery. 
Most  unhappily,  physicians  cannot  always  detect,  or,  if  detected, ! 
cannot  always  remove  such  causes;  and  the  patient  wears  away 
her  tedious  life  in  pain  and  anguish.     Fortunately,  however,  in  a 
large  majority  of  cases,  the  cause  can  be  detected  and  removed. 
The  author's  experience  is  very  favorable  as  to  the  rapid  recovery 
of  such  patients;  and  such  recoveries  are  often  accomplished  by 
rectifying  deviated  positions  of  the  uterus. 


PROGNOSIS. 

As  to  the  ■prognosis^  therefore,  in  irritable  or  nervous  diseases,   -(. 
everything — radical — depends  on  removing  the  cause  of  the  irri- 
tation.    Displacements  of  the  uterus  are,  as  already  stated,  by  far 
the  most  frequent  cause. 

The  prognosis  as  regards  displacements  of  the  uterus  is  exceed- 
ingly favorable.  The  physician  ought  to  succeed  in  all  uncom- 
plicated cases,  even  in  retroversion  and  retroflexion,  which  are 
the  most  difficult  to  manage,  and  often  require  much  time  and 
perseverance. 

C  In  deviations  of  the  uterus,  where  the  organ  is  hypertrophied, 
indurated,  or  loaded  with  heterologue  tumors,  or  where  its  dis- 
placement is  maintained  by  tumors  of  the  pelvis,  of  the  ovaries, 
of  the  mesentery,  etc.,  or  by  adhesions  to  surrounding  organs, 
great  difl&culty  is  necessarily  experienced.  -)  So,  also,  in  contrac- 


866      SYMPTOMS    OF    DISPLACEMENTS    OF    THE    UTERUS. 

tions,  or  other  unnatural  states  of  the  vagina,  it  may  be  almost 
impossible  to  rectify  the  position  of  the  uterus.  Yet,  there  are 
but  few  cases  in  which  a  partial,  if  not  a  complete  relief,  cannot 
be  afforded.  Patience  and  perseverance  in  the  judicious  use  of 
mechanical  aids,  will,  under  the  direction  of  science  and  expe- 
rience, afford  prospect  of  great  success. 

There  are,  of  course,  cases  in  which  other  causes  of  pain  and 
irritation  exist,  independently  of  the  displacement.  This  last, 
therefore,  may  sometimes  be  completely  relieved,  and  3^et,  the 
irritation  be  kept  up  by  the  other  causes  in  a  greater  or  less 
degree.  These  causes  are  often  inscrutable ;  they  sometimes 
cannot  be  detected ;  and  hence,  these  patients  are  sufferers  for 
life,  or  at  least  until  there  is  a  revolution  in  the  nervous  system, 
such  as  occurs  at  the  cessation  of  the  menstrual  secretion;  or, 
until,  from  natural,  unassisted  efforts,  the  local  irritation  has  dis- 
appeared. Almost  any  practitioner  is  familiar  with  cases  of 
neuralgia  which  he  and  perhaps  many  others  have  treated  by 
every  available  method,  it  may  be,  for  years,  ineffectually ;  yet 
suddenly,  perhaps,  when  no  measures  were  resorted  to,  the  pain 
ceased,  and  the  patient  returned  to  the  full  enjoyment  of  health 
and  strength.  Such  cases  have  often  given  a  meretricious  repu- 
tation to  infinitesimal  doses  and  innumerable  empirical  remedies, 
which  might  have  been  accidentally  emploj^ed  at  the  time. 

We  have  had  many  cases  of  these  irritable  diseases  of  females, 
in  which  the  symptoms  have  been  greatly  palliated  by  a  partial 
removal  of  the  cause ;  yet,  complete  recoveries  have  not  been 
effected,  as  a  displacement  or  other  cause  was  but  partially 
obviated. 

The  principle  is  true,  therefore,  however  difficult  it  may  some- 
times be  of  practical  application,  through  our  ignorance  or  the 
inefficiency  of  our  means,  that  nervous  diseases  are  kept  up  by 
the  continuance  or  the  return  of  exciting  causes,  and  that  these 
causes  being  removed,  nervous  affections,  which  are  by  many 
considered  so  indomitable,  will  be  readily  relieved.  We  must 
believe,  also,  that  the  most  frequent  exciting  causes  of  these  com- 
plaints are  displacements  of  the  uterus,  and  that  the  scientific 
treatment  of  uterine  deviations  is  one  of  the  most  important 
elements  in  the  management  of  cerebro-spinal  diseases. 


TEEATMENT    OF    DISPLACEMENTS    OF    THE    UTERUS.      367 


CHAPTER    IV. 

TREATMENT   OF   DISPLACEMENTS   OF    THE    UTERUS. 

In  the  treatment  of  the  various  displacements  of  the  uterus, 
there  are  four  indications  to  be  fulfilled. 

First.  To  remove  or  palliate  any  existing  causes. 

Second.  To  replace  the  organ. 

Third.  To  maintain  it  at  all  times  in  situ  naiurali,  and  to  allow 
of  its  natural  motions. 

Fourth.  To  strengthen  the  natural  supports  of  the  uteras. 

TO  REMOVE  OR  PALLIATE  ANY  EXISTING  CAUSES. 

This  first  indication  is  of  great  importance,  and  can  in  many 
instances  be  readily  carried  out. 

Teansitory  Causes. — Many  of  the  causes  are  transitory,  such 
as  jumping,  straining,  etc.,  and  therefore  disappear  at  once ;  besides 
these,  there  are  many  of  daily  recurrence  which  can,  however, 
readily  be  obviated,  such  as  all  compression  of  the  abdomen 
by  tight  dresses,  corsets,  ligatures,  and  abdominal  supporters. 
Again,  all  distensions  of  the  abdominal  viscera,  from  too  full  a 
diet,  from  flatulency,  constipation,  or  distension  of  the  bladder, 
can  usually  be  prevented  by  judicious  attention  to  diet,  drinks, 
carminatives,  laxatives,  and  other  appropriate  measures,  hygienic 
or  medical. 

Persistent  Causes. — The  more  permanent  causes,  such  as 
hypertrophies,  can  be  removed  or  palliated  according  to  their 
origin. 

Hypertrophy  arising  fropi  Polypi  can  be  obviated  by  removing 
these  tumors. 

When  from  Pregnancy,  the  increased  size  may  be  palliated  by 


368      TREATMENT    OF    DISPLACEMENTS    OF    THE    UTERUS. 

constant  rest  in  bed,  or  by  the  use  of  an  internal  supporter,  until 
the  end  of  the  third  or  fourth  month  of  gestation,  when  there  can 
be  no  longer  any  pelvic  displacement. 

Hypertrophies  of  the  organ,  from  tumors  in  its  suhstance  or  on 
its  surfaces  which  cannot  be  eradicated ;  as  well  all  enlargements 
and  indurations  of  the  organ  from  inflammation,  or  other  dis- 
eased states,  remain  permanent,  and  can  merely  be  palliated  by  a 
proper  internal  support.  The  same  observation  applies  to  all 
ovarian,  mesenteric,  and  other  tumors  in  the  abdominal  cavity ;  to 
enlargements  of  the  liver,  sjjleen,  kidneys,  etc.,  which  might,  directly 
or  indirectly,  influence  the  position  of  the  uterus ;  also  to  the 
pressure  arising  from  peritoneal  tympanites,  from  peritoneal  or 
encysted  dropsies,  etc.  In  all  such  cases,  great  relief  may  often  be 
afforded,  although  the  cause  cannot  be  obviated  by  the  usual 
mechanical  treatment  for  the  displacement. 

When  symptoms  of  displacement  arise  suddenly  from  active 
engorgement  of  the  uterus,  and  especially  from  acute  inflammation, 
such  vascular  excitements  must  be  removed  by  suitable  revulsive, 
alterative,  and  evacuating  remedies,  which  will  often  be  effectual 
in  removing  all  symptoms  of  displacement.  In  chvnic  inflam- 
mation of  the  body  of  the  uterus,  medicinal  measures  should  be 
employed  until  inflammatory  symptoms  are  removed.  When 
the  inflammation  is  confined  to  the  cervix,  and  is  of  a  strictly 
chronic  character,  the  use  of  antiphlogistic  measures  may  be 
greatly  assisted  by  suitable  pessaries  of  a  ring  shape.  The 
modus  operandi  of  such  supports  is  twofold :  flrst,  they  relieve 
the  neuralgic  pains,  and  the  spinal  and  cerebral  irritations  arising 
from  the  displacement;  and  second,  they  remove  a  constant,  un- 
ceasing source  of  irritation  to  the  cervix  from  pressure  of  this 
inflamed  tissue  on  the  walls  of  the  vagina  and  rectum.  This 
point  has  already  been  dwelt  upon,  and  we  feel  well  assured  that 
a  large  number  of  the  chronic  inflammations  of  the  os  uteri,  espe- 
cially of  the  so-called  ulcerations  of  the  os  and  cervix,  are  kept 
up  by  this  cause,  and  are  aggravated  by  constant  and  repeated 
caustic  and  irritating  applications.  The  simple  preventing  of  the 
pressure  on  the  cervix  by  a  ring  pessary  will,  by  removing  the 
cause,  original  or  aggravating,  wonderfully  facilitate  the  efficacy 
of  the  most  simple  washes  in  destroying^  superficial  inflammations, 
and  in  discussing  even  the  deep-seated  inflammations  of  the  cervix 
uteri.     Such  cases  are  numerous,  and  we  can  bear  testimony  that, 


TO  REPLACE  THE  UTERUS.  369 

except  in  cases  of  preternatural  growths  and  malignant  diseases 
of  the  cervix,  we  have  never  found  the  employment  of  power- 
ful caustics  useful  in  inflammatory  affections.  The  occasional 
application  of  the  solid  nitrate  is  sometimes  advantageous  in 
diminishing  the  irritability  of  the  cervix,  at  least  for  the  time ; 
but  solutions  -of  this  salt,  of  alum,  of  borax,  of  sulphate  of  zinc, 
of  sulphate  of  copper,  and  other  analogous  preparations,  are,  in 
our  hands,  sufficient  for  the  resolution  of  such  inflammatory 
affections,  when  assisted  by  a  suitable  ring  pessary,  properly 
adjusted.^ 

Remarks. — But  the  fulfilment  of  the  first  indication  is  seldom 
sufficient.  For  if  the  ligaments  of  the  uterus  have  once  been 
elongated  to  such  a  degree  that  their  natural  elasticity  and  con- 
tractility have  been  lost,  the  mere  removal  of  the  original  cause 
will  not  be  sufficient  for  the  restitution  of  this  organ  ;  inasmuch 
as  the  mere  weight  of  the  intestines  and  the  contraction  of  the 
abdominal  muscles  must  keep  it  depressed. 

TO  REPL^JE  THE  UTERUS  IN  ITS  NATURAL  POSITION. 

This  second  indication  is  sometimes  a  very  easy  operation,  but 
occasionally  difficult,  and  at  times  impracticable. 

In  anteversion  and  simple  prolapsus^  pressure  with  the  finger 
will  for  the  time  accomplish  the  object.  In  almost  all  cases  of 
procidentia^  unless  very  unusual  enlargement  exists,  the  uterus  can 
be  readily  reduced,  so  as,  at  least,  to  re-enter  the  pelvis. 

In  cases  of  retroversion^  and  especially  of  retroflexion^  it  is  more 
difficult,  for  the  fundus  has  to  be  raised  from  the  hollow  of  the 
sacrum,  so  as  to  approximate  the  pubis.  In  some  instances  this 
can  be  accomplished  by  the  finger  alone,  in  the  vagina  or  in  the 
rectum,  assisted  by  a  proper  position  of  the  patient,  generally  on 
the  knees  and  elbows;  but  this  restoration  is  seldom  practicable, 
especially  in  women  who  have  not  borne  children. 

'  Dr.  J.  T.  Sliarpless,  of  this  city,  in  a  small  pamplilet  on  the  "  Use  and  Abuse 
of  Pessaries,"  published  in  1837,  inculcates  similar  views  on  the  utility  of  pes- 
saries during  inflammatory  irritations  of  the  cer-vix.  He  advises  the  use  of  a  ring 
pessary,  where  there  is  a  slight  cervical  endometritis  in  conjunction  with  astrin- 
gent washes  ;  and  also  where  cicatrices  had  formed  after  the  healing  of  ulcers 
similar  protection  to  the  cervix  is  valuable,  as  preventing  the  irritations  resulting 
from  friction,  and  the  return  of  the  disease. 

24 


M- 


370      TREATMENT    OF    DISPLACEMENTS    OF    THE    UTERUS. 

Elevators. — Dr.  Bond's  elevators,  the  colpeurjnter,  or  gum  elas- 
tic bag,  and  other  instruments,  acting  per  rectum  or  per  vaginam, 
have  been  used  as  a  substitute  for  the  finger  in  restoring  the  ute- 
rus to  its  position.  If  the  organ  be  easily  movable,  they  may 
sometimes  be  effectual. 

The  uterine  prohe  or  sound,  of  a  suitable  curvature,  and  a  pro- 
perly shaped  pessary,  are  the  only  ef&cient  instruments  for  restor- 
ing the  uterus  to  its  normal  position  ;  and  they  will  always  answer, 
provided,  of  course,  there  be  no  adhesions,  no  large  tumors,  and 
no  contractions  of  the  vagina,  to  mechanically  resist  their  safe 
operation, 
-f  Simpson's  uterine  sound,  with  its  convexity  towards  the  pubis, 
may  be  slowly  and  carefully  introduced  into  the  retroverted 
uterus  by  directing  its  point  backwards  towards  the  sacrum. 
Then,  by  slowly  revolving  the  probe,  so  that  its  concavity  shall 
be  turned  towards  the  pubis,  the  instrument,  acting  on  the  interior 
of  the  uterus,  will  gradually  elevate  the  fundus  from  the  sacram 
to  its  natural  position.  This,  however,  is  a  very  painful  opera- 
tion to  some  patients,  sometimes  almost  insupportable,  and  gene- 
rally followed  by  an  effusion  of  blood  and  by  some  soreness  of 
the  womb.  An  ingenious  modification  of  the  sound  as  an  eleva- 
tor, suggested  by  Dr.  J.  Marion  Sims,  of  a  joint  at  the  junction 
of  the  uterine  and  vaginal  portions  of  the  probe,  may  obviate 
some  of  these  difficulties,  but  is  too  complicated  for  common 
practice. 

A  curved  pessary,  such  as  will  hereafter  be  described,  may  as 
readily  accomplish  the  same  object  when  the  vagina  is  relaxed, 
with  comparatively  little  pain,  and  no  subsequent  irritation ;  and, 
if  allowed  to  remain,  it  will  preserve  what  has  been  gained.  In 
other  cases  it  accomplishes  the  object  more  gradually  but  cer- 
tainly, operating  day  after  day  till  the  indication  is  fulfilled.  The 
curved  pessary  is  the  best  elevator,  for  it  is  permanent  in  its  in- 
fluences. The  modus  operandi  of  pessaries,  in  this  and  other 
respects,  will  be  hereafter  detailed. 

,       Eemarks. — In  very  few  cases,  however,  will  any  advantage  . 
result  from  the  mere  replacement  of  the  organ,  when  no  measures 
are  adopted  to  keep  it  in  situ.     As  the  natural  supports,  the 
ligaments,  etc.,  have  become  inefficient;  and  as  the  uterus,  even 
in  the  recumbent  position  of  the  patient,  has  always  to  sustain  a 


TO  MAINTAIN  THE  UTERUS.  37L 

pressure  from  the  intestines,  and  from  the  contraction  of  the  abdo- 
minal muscles,  aggravated  by  a  deep  inspiration,  by  every  motion 
in  bed,  by  coughing,  by  sneezing,  by  the  evacuation  of  the  urine, 
of  the  faeces,  etc.:  elevators  of  whatever  kind  are  scarcely  removed 
before  the  displacement  recurs.  Such,  at  least,  is  the  result  of 
the  author's  reiterated  observation,  although  other  practitioners 
have  given  different  reports.  Certainly,  however,  there  will  be 
a  return  of  the  displacement  on  every  attempt  at  locomotion. 
So  that  the  mere  replacement  of  the  uterus  may  be  regarded  as 
worse  than  useless,  as  it  gives  the  patient  the  pain  and  irritation 
of  a  disagreeable  operation,  which  cannot  be  permanently  effectual. 
The  only  exceptions  to  these  remarks  are  in  cases  of  pregnancy, 
at  the  third  or  fourth  month,  and  in  enlargements  of  the  organ 
from  other  causes ;  then,  owing  to  the  size  of  the  uterus,  it  may 
be  supported  sufficiently  by  the  parietes  of  the  pelvis,  and  its  sub- 
sequent developments  will  insure  the  permanency  of  its  rectifica- 
tion. After  delivery  also,  the  replacing  of  the  organ,  if  deviated 
from  its  position,  keeping  the  patient  strictly  in  the  recumbent 
position,  and  avoiding  most  carefully  all  straining  efforts  at  stool, 
etc.,  may  be  effectual ;  inasmuch  as  there  is  a  natural  disposition 
of  the  ligaments  elongated  during  gestation  to  contract,  which 
disposition  would  be  resisted  by  the  displacement,  and,  of  course, 
be  facilitated  by  frequently  replacing  the  organ.  Nevertheless, 
we  have  been  so  frequently  mortified  by  the  failure  of  this  plan, 
and  by  our  patient's  chagrin  at  the  return  of  the  symptoms  of 
displacement,  even  after  a  protracted  wearisome  confinement  in  a 
horizontal  position,  that  we  have  abandoned  it  altogether.  To 
maintain  as  w^ell  as  replace  is  the  proper  indication  in  such  cases ; 
this,  if  fulfilled,  gives  no  discomfort  and  allows  the  patient  to 
desert  her  bed  at  pleasure. 


TO  MAINTAIN  THE  UTERUS  IN  ITS  NATURAL  POSITION. 

This  is  the  third  and  important,  indeed  essential,  indication  in 
the  management  of  displacements  of  this  influential  organ. 

To  fulfil  this  indication  is  a  problem  of  great  difficulty,  yet 
perhaps  to  be  completely  solved ;  for,  after  all  the  attention  and 
ingenuity,  and  even  science,  which  have  been  directed  to  this  point 
in  times  past  and  present,  no  suggestion  has  received  the  general 


872      TREATMENT    OF    DISPLACEMENTS    OF    THE    UTERUS. 

sanction  of  the  profession.  Innumerable  as  liave  been  these 
suggestions,  each  has  but  a  limited  number  of  supporters.  Many 
physicians  have  avoided  such  cases  entirely,  surrendering  them 
to  every  variety  of  empirical  experiments ;  so  that  women  remain 
too  often  wretched  sufferers,  spending  days,  months,  and  years,  a 
prey  to  disorders  which  disturb  every  corporeal  function,  and 
which  often  pervert  the  whole  intellectual  and  spiritual  being. 

There  have  been  no  lack  of  ingenuity,  and  no  want  of  experi- 
ments with  more  or  less  success,  but  these  efforts  have  not  been 
generally  well  directed ;  the  proper  position  of  the  organ  in 
health,  its  means  of  support,  and  the  suitable  scientific  indications 
to  be  kept  in  view  for  the  relief  of  displacements,  have  not  been 
suf&ciently  developed.  There  are,  however,  intrinsic  difficulties 
in  all  mechanical  arrangements  operating  on  vital  tissues  endowed 
with  sensibility,  which,  in  these  cases,  is  often  terribly  exalted ; 
in  addition  to  this  there  is  always  present  the  opposition  from  the 
weight  of  the  superincumbent  viscera  and  the  great  pressure 
from  the  abdominal  parietes,  under  the  ever  varying  positions 
and  motions  to  which  the  body  is  constantly  subjected. 

These  difficulties  will  be  fully  presented  in  the  review  of  the 
most  important  suggestions  which  have  been  made  for  the  sus- 
tentation  of  the  uterus  in  situ  naturali.  The  criticisms  ventured 
on,  in  these  suggestions,  will  be  found  presented,  it  is  hoped,  in 
a  just  and  candid  manner,  as  the  result  of  personal  experience  or 
observation  in  the  numerous  cases  at  home  and  from  abroad, 
which  have  passed  under  the  author's  supervision. 

Eest  in  Bed. — In  order  to  fulfil  this  indication  of  maintaining 
the  uterus  in  situ,  rest  in  hed^  with  a  careful  avoidance  of  all 
straining  efforts,  has  been  much  insisted  upon,  theoretically  and 
practically.  Often,  the  patient  has  been  constantly  kept  for 
many  months,  without  the  least  intermission,  on  her  back,  with 
merely  a  low  pillow  for  the  head.  In  other  cases,  when  retro- 
version was  suspected,  the  woman  has  been  forced  to  lie  upon  the 
abdomen,  and  often  to  spend. much  time  on  her  knees  and  elbows. 
Many  patients  have  passed  months  on  the  back,  with  the  pelvis 
bolstered  up  by  pillows,  and  the  head  dependent,  so  that  gravity 
should  be  enabled  to  remove  the  intestines  from  the  uterus;  the 
practitioner  forgot  that  the  cavity  of  the  abdomen  was  a  plenum, 
and  that  the  contraction  of  the  abdominal  muscles  and  diaphragm 


REST    IN    BED.  373 

acted  in  opposition  to  tlie  ascent  of  the  intestines  towards  the 
chest. 

Rest  diminishes,  but  does  not  by  any  means  remove  the  pres- 
sure from  the  uterus.  In  many  patients,  perfect  ease  and  freedom 
from  paia  are  experienced  on  recumbency ;  yet,  although  the 
organ  may,  by  some  diminution  of  pressure,  be  partially  restored, 
it  is  not  completely  reinstated,  the  ligaments  are  still  on  the 
stretch,  and  the  moment  the  patient  rises,  her  bad  feelings  return. 
How  often  do  women  affirm,  that  before  rising  in  the  morning, 
they  feel  perfectly  well  and  able  to  do  anything;  but  a  few 
moments'  experience  out  of  bed  brings  bitter  disappointment. 
There  is  no  restorative  power  in  rest ;  it  palliates,  but  does  not 
cure,  because  the  ligaments  are  kept  elongated  by  the  unceasing 
pressure  from  above,  continually  increased  by  every  muscular 
effort  of  the  abdominal  tissues. 

As  a  preventive  to  displacements,  rest  is  often  of  great  value, 
particularly  after  abortions  and  delivery  at  term,  when  the  uterus 
is  large,  and  there  is  a  natural  disposition  to  contraction  on  the 
part  of  the  uterus  and  the  ligaments.  Hence,  there  is  some  truth 
in  the  popular  notion,  that  pregnancy  is  the  best  cure  for  a  dis- 
placed uterus.  Displacement  disappears  when  the  uterus  rises 
out  of  the  pelvis  at  the  sixteenth  week  of  gestation ;  and  after 
delivery,  perfect  rest,  conjoined  with  proper  attention,  for  some 
four  or  six  weeks,  may  insure  a  complete  recovery.  The  reverse, 
however,  is  the  usual  experience,  as  most  patients  date  the  occur- 
rence of  pelvic  trouble  from  one  of  their  confinements. 

In  what  may  be  called  acute  cases  of  displacement,  as  when 
some  deviation  has  been  suddenly  caused  by  a  severe  strain,  a 
muscular  effort,  or  great  distension  of  the  abdomen,  then  by  rest 
in  bed,  by  keeping  the  bladder  empty,  and  the  bowels  free,  the 
contractility  of  the  ligaments  may  be  sufficient  for  a  restoration. 
These  are  rare  and  exceptionable  cases. 

Rest,  as  a  cure  for  displacement,  has  been  advocated  on  another 
principle,  namely,  that  displacements  are  owing  to  congestion,  or 
inflammation  of  the  uterus.  By  perfect  quietude  the  vascular 
fulness  is  overcome,  and  the  displacement  relieved.  The  answer 
to  this  is  twofold:  if  the  assertion  be  true,  the  disease  to  be  cured 
is  not  displacement,  but  congestion;  the  symptoms  depend  on 
the  fulness  of  the  vessels,  and  not  on  a  change  of  position  of  the 
organ ;  just  as  there  are  few  women  who  have  not  some  of  these 


374      TREATMENT    OF    DISPLACEMENTS    OF    THE    UTERUS. 

so-called  symptoms  of  displacement  at  their  catamenial  periods, 
which  disappear  either  daring  or  after  the  flow  of  the  menses. 
The  second  answer  to  this  view  of  the  case  is,  that  the  conges- 
tion is  not  the  cause  of  the  displacement,  but  its  consequence,  as 
has  been  proved  in  all  chronic  cases,  and  even  in  most  of  the 
acute  forms.  The  facts  in  support  of  this  opinion  have  already- 
been  detailed  at  length ;  suffice  it  at  present  to  say,  that  the  treat- 
ment by  rest  and  evacuants,  both  general  and  local,  we  have 
often  known  carried  on  for  months  and  years,  not  only  without 
permanent  relief,  but  even  with  great  aggravation  of  all  the 
symptoms,  especially  of  those  dependent  on  irritation  of  the 
cerebro-spinal  nervous  system ;  while,  on  the  contrary,  by  re- 
lieving the  displacement — the  cause  of  the  irritation — the  con- 
gestion has  disappeared,  and  also  the  nervous  s3Tnptoms  resulting 
from  pain,  confinement,  and  exhaustion. 

Eest  conjoined  WITH  ASTRINGENTS.  —  Most  practiiioners, 
however,  do  not  trust  to  rest  alone,  but  conjoin  with  perfect 
quietude  of  the  body  the  rise  of  astringents  of  every  variety  and 
by  every  means  of  application,  to  effect  the  contraction  of  the 
vaginal  tube  so  as  to  aftbrd  a  support  to  the  uterus. 

It  is  useless  to  specify  the  details  of  this  treatment.  Its  entire 
insufficiency  has  been  demonstrated  in  thousands  of  cases;  and 
the  reason  of  its  failure  has  already  been  exhibited  sufficiently 
when  describing  the  natural  supports  of  the  uterus.  It  seems 
impossible  for  any  mechanician  to  conceive  that  a  soft,  flexible, 
and  distensible  tube,  some  three  or  four  inches  in  length,  having 
the  uterus  attached  to  its  upper  extremity,  and  running  at  an  acute 
angle  to  this  organ,  could  give  any  adequate  support  to  it  even  in 
a  state  of  health.  The  uterus  may  descend  or  ascend  ;  the  fundus 
may  be  turned  forwards,  or  backwards  to  any  extent ;  flexion, 
anteriorly  or  posteriorly,  may  occur ;  yet  the  natural  contraction 
and  tonicity  of  the  vagina,  in  the  young  virgin,  may  at  the  same 
time  exist  in  all  its  original  integrity.  Even  the  tube  may  be  pre- 
ternaturally  contracted  by  spasms,  by  deformities,  by  adhesions, 
and  by  obliteration  of  its  cavity,  and  yet  painful  displacements  of 
the  uterus  may  exist.  Surely,  therefore,  any  temporary  contrac- 
tion of  this  vulvo-uterine  canal,  by  the  most  powerful  astringents 
(for,  after  all,  the  contraction  is  temporary),  must  be  unavailing  in 
replacing  or  maintaining  a  uterus,  which  has  been  for  any  length 


OPERATIONS    UPON    THE    VAGINA.  375 

of  time  displaced.  The  unvarying  experience  of  the  author  veri- 
fies these  opinions,  and  confirms  the  facts  now  stated.  Cold  and 
astringent  washes  have,  of  course,  their  own  appropriate  advan- 
tages in  diminishing  irritations,  checking  discharges,  removing 
inflammations,  clearing  the  passage,  preventing  acrid  accumula- 
tions, facilitating  natural  secretions  and  excretions,  and  giving 
tone  to  the  tissues,  but  are  altogether  uniuflueutial  upon  the 
position  of  the  uterus  in  the  pelvis. 

Operations  upon  the  Vagina. — The  theory  that  the  con- 
traction of  the  vagina  is  requisite  to  the  support  of  the  uterus, 
has  been  carried  to  a  much  more  serious  and  even  dangerous 
practice. 

Dieffenbach,  Gerardin,  Berard,  and  many  others  in  Europe  and 
America,  have  resorted  to  the  knife  to  fulfil  this  false  indication. 
Strips  of  the  mucous  membrane  of  the  vagina,  sometimes  oval 
or  crescentic,  but  more  frequently  of  a  triangular  form,  and  ex- 
tending longitudinally  from  the  vulva  to  the  uterus,  have  been 
elaborately  dissected  off,  and  the  edges  of  the  wound  brought 
into  contact,  so  that,  after  adhesion  has  ensued,  there  may  be  a 
permanent  contraction  of  the  passage.  Others  have  closed  the 
whole  orifice  of  the  vagina  by  causing  adhesions  to  occur  so  ex- 
tensively as  merely  to  leave  a  fistulous  opening  for  the  exit  of 
the  menstrual  excretion.  Like  all  novelties,  these  operations 
upon  their  introduction  received  much  attention,  and  many 
favorable  results  were  reported ;  but  they  have  not  obtained  the 
general  confidence  of  the  profession.  Certainly,  in  all  the  usual 
displacements  of  the  uterus,  they  are  unnecessary,  and,  according 
to  the  views  above  presented,  would  generally  be  ineffectual. 

In  cases  of  procidentia  uteri,  at  first  sight  the  suggestion  ap- 
pears to  be  valuable,  and  it  has  been  chiefly  confined  to  cases  of 
this  character.  In  such  instances  there  will  be  a  partial  success, 
and  perhaps,  to  some  patients,  complete  relief.  But  even  here  the 
operation  is  not  defensible,  for  it  is  often  difficult  of  execution,  and, 
as  in  all  cases  of  operations  with  the  knife,  especially  upon  the 
internal  tissues  of  the  body,  involves  many  dangers  from  hemor- 
rhage and  inflammation — simple,  erysipelatous,  or  even  gangren- 
ous, especially  as  the  patients  are  frequently  in  a  bad  state  of 
health  from  the  long  continuance  of  their  sufferings  and  confine- 
ment.    There  is  danger,  also,  of  injuring  the  important  tissues 


376      TREATMENT    OF    DISPLACEMENTS    OP    THE    UTERUS. 

of  the  peritoneum  and  of  the  bladder  or  rectum,  either  by  the 
scalpel  of  the  operator,  or  bj  subsequent  sloughing,  so  that  a 
vesico-vaginal  or  a  vagino-rectal  fistula,  with  all  its  disgusting 
consequences,  may  ensue.  Of  course,  in  some  instances,  even 
fatal  results  may  follow.^ 

Another  argument,  in  addition  to  the  above  is,  that,  at  best, 
the  operation  can  be  but  partially  successful.  It  may  sometimes 
prevent  procidentia  very  effectually  by  shutting  up  the  uterus 
within  the  vulva ;  but  it  can  have  no  effect,  as  shown  by  the  facts 
already  adduced,  in  preventing  the  continuance  of  a  prolapsus, 
anteversion,  or  retroversion  of  the  uterus.  Indeed,  a  retroversion 
will  generally  be  found  to  exist  in  such  instances,  inasmuch  as,  as 
has  already  been  demonstrated,  retroversion  precedes  necessarily 
a  procidentia  uteri ;  and  the  contraction  of  the  vagina  by  adhe- 
sions, even  to  perfect  atresia  vaginae,  will  not  only  allow  a  retro- 
version to  exist,  but  may  maintain  the  organ  in  this  mal-position. 

Another  suggestion  for  contracting  the  vagina  is  by  "serre- 
fines,"  or  short  double  spring  hooks.  A  few  of  these  can  be  easily 
arranged  in  the  vagina,  so  as  to  pinch  up  and  thus  retain  portions 
of  the  mucous  membrane  until  some  inflammation  has  taken  place, 
and  the  tissues  become  adherent  and  somewhat  thickened.  The 
operation  may  be  occasionally  repeated.  We  have  observed  no 
special  reports,  either  as  to  the  frequency  or  success  of  this  plan. 

Another  suggestion  is  to  excite  inflammation  or  even  ulceration 
by  caustics,  more  or  less  severe.     This  plan  has  generally  been 

'  Comparatively  little  success  has  followed  this  operation.  Our  countryman,  Dr. 
J.  Marion  Sims,  and  his  colleague,  Dr.  T.  A.  Emmet,  of  New  York,  have  somewhat 
modified  the  operation  by  removing  strips  of  the  mucous  membrane  of  a  V  or 
sometimes  of  a  triangular  shape,  and  drawing  the  denuded  surfaces  together  by 
silver  sutures.  They  give  encouraging  accounts  of  their  success,  although  they 
acknowledge  some  cases  of  failure.  Certainly  the  operation  demands  nice  and 
delicate  manipulation,  and  cannot,  at  any  time,  be  considered  free  from  danger  ; 
neither  can  it  have  any  effect  in  relieving  ante  or  retroversion  of  the  uterus  which 
may  coexist  with  the  procidentia ;  for  as  Mr.  Wright  says,  the  movenaents  of  the 
body  of  the  uterus,  anteriorly  or  posteriorly,  are  above  and  outside  of  the  vagina. 

Dr.  Emmet  has  published  in  pamphlet  form  (from  the  New  York  Medical  Jour- 
nal, January,  1865)  an  account  of  his  modified  triangular  operation,  reporting 
seventeen  cases  as  being  apparently  perfectly  cured.  He  says  that  similar  ope- 
rations may  be  performed  for  cyslocele  and  rectocele.  Nevertheless,  he  regards 
it  as  a  formidable  operation,  by  no  means  easy  of  execution,  and  as  occasionally 
failing.     He  wduld  restrict  it  to  old  cases  of  procidentia. 


EXTERNAL    BANDAG-ES,  377 

condemned  as  very  uncertain,  and  always  dangerous,  as  the  extent 
of  the  ulceration  or  sloughing  cannot  be  previously  estimated. 
The  subjacent  tissues  might  be  seriously  involved. 

The  strongest  argument,  however,  against  such  operations  is, 
that  they  are  altogether  unnecessary.  In  all  cases,  in  the  expe- 
rience of  the  author,  of  reducible  procidentia  uteri,  this  organ  and 
the  vagina,  however  relaxed,  can  be  maintained  perfectly  in  their 
normal  positions  by  means  of  suitable  pessaries ;  and  this  is  true 
even  in  cases  where  the  perineum  has  been  lacerated  so  as  to 
involve  the  sphincter  ani. 

BxTERisrAL  Bandages, — No  permanent  relief  being  obtained 
by  rest,  position,  and  astringents,  the  use  of  external  landages 
under  the  various  names  of  braces,  abdominal  or  utero-abdominal 
supporters,  abdominal  corsets,  spinal  supporters,  etc.,  has  been 
resorted  to  by  patients,  by  empirics,  and  even  by  the  mass  of  the 
profession. 

This  is  probably  a  most  ancient  practice;  it  may  have  been 
contemporaneous  with  the  first  woman  who  seriously  suffered  from 
a  displaced  uterus.  The  wretched  sensation  of  weakness  in  the 
loins,  the  feeling  of  emptiness  or  vacuity  in  the  abdomen,  the 
bearing-down,  and  the  sensation  of  "  openness"  at  the  vulva,  as  if 
everything  would  escape,  almost  unconsciously  induce  the  poor 
suffferer  to  press  her  hand  on  the  abdomen  or  on  the  perineum 
for  relief,  and  thus  a  temporary  mitigation  of  suffering  is  expe- 
rienced. A  more  permanent  effect  is  soon  obtained  by  a  towel 
pinned  around  the  abdomen,  or  by  napkins  bound  against  the 
perineum. 

These  feminine  suggestions  have  stimulated  the  ingenuity  of 
empirics  and  of  physicians ;  so  that  almost  every  imaginable  form 
of  compresses  and  braces,  non-elastic  and  elastic,  for  the  support 
of  the  uterus  and  the  parietes  of  the  abdomen,  have  been  succes- 
sively introduced.  The  apparent  success  has  been  so  great,  that 
not  only  have  the  supporters  crept  into  general  use ;  but  the 
principle  of  avarice  has  conjoined  with  the  love  of  doing  good, 
so  that  every  trifling  modification  of  the  material,  of  the  size  and 
form  of  the  compress,  or  the  particular  part  on  which  it  is  to 
operate,  has  been  magnified,  as  if  of  the  greatest  importance,  and 
physicians,  graduates  in  medicine,  have  disgraced  themselves  and 
the  profession  which  tolerates  them,  by  obtaining  "patents"  for 


878      TREATMENT    OF    DISPLACEMENTS    OF    THE    UTERUS. 

the  exclusive  sale  of  their  own  trifling,  if  not  ridiculous  varieties 
of  a  feminine  girdle.  It  would,  be  interminable,  as  well  as  useless 
to  describe  the  innumerable  forms  of  these  supporters,  with  or 
without  the  perineal  strap — which  renders  them  a  modification  of 
the  old  and  useful  T  bandage  of  the  surgeons — as  thej  all  act  on 
the  same  principle,  and  are  productive  of  the  same  results. 

The  strong  and  almost  the  sole  argument  for  their  employment, 
is  the  experience  of  the  patient.  A  very  large  number  find  imme- 
diate relief  to  many  of  their  symptoms,  on  applying  a  bandage ; 
many  say  they  can  walk  distances  with  these  supports,  and  are 
confined  to  the  house  when  without  them ;  many  cannot  move  or 
even  stand  without  their  assistance.  We  have  had  patients  who 
declared  that  if  the  house  were  on  fire,  or  their  child  in  convul- 
sions, they  could  not  stir  without  previously  arranging  their 
girdle.  This  is  strong  testimony,  and  fully  justifies  a  bedridden 
patient  in  resorting  to  this  simple  apparatus,  that  she  may  attend 
to  the  duties  of  her  household.  It  would  seem,  also,  to  justify  the 
profession  in  the  recommendation  of  these  bandages  to  their 
miserable  patients. 

Ohjections. — Enlarged  experience  and  careful  observation  falsify 
most  of  these  fair  prognostications.  There  are  innumerable  cases 
in  which  these  bandages  cannot  be  tolerated  even  for  a  short  period. 
The  sensitiveness  of  the  parietes  of  the  abdomen,  of  the  internal 
tissues  and  of  the  pelvic  viscera,  renders  the  pressure  of  the  pads 
or  of  the  girdle  intolerable.  Many,  who  can  wear  them,  find  no 
relief;  and  in  those  more  favorable  cases,  where  they  have  been 
worn  for  years,  their  beneficial  influences  decline  and  often  dis- 
appear. Even  in  these  cases  the  relief  is  but  partial,  as  generally 
some  of  the  old  symptoms  pertinaciously  remain.  We  have  had 
many  patients  who  have  worn  these  supporters  for  years,  and 
could  not,  on  an  emergency,  cross  a  room  without  them ;  yet 
during  the  whole  time  they  had  never  walked,  even  with  their 
assistance,  in  a  continuous  path,  a  distance  of  one  hundred  yards, 
and  were  tormented  with  leucorrhoea,  dysmenorrhoea,  dyspepsia, 
cephalalgia,  or  other  variety  of  local  or  sympathetic  irritation. 
Abdominal  supporters  should,  therefore,  be  regarded  at  best  as 
but  palliatives  to  some  of  the  urgent  symptoms,  but  often  ineffi- 
cient even  in  this  respect,  and  in  many  cases  intolerable. 

Minor  Ohjections. — Even  when  patients  can  wear  these  sup- 
porters with  impunity  and  apparent  advantage,  there  are  nume- 


OBJECTIONS    TO    BANDAGES.  379 

rous  inconveniences  wliicli  render  them  often  very  objectionable 
and  onerous ;  for  example,  the  necessity  of  constantly  removing 
and  replacing  the  bandage ;  their  friction  on  delicate  and  irritable 
parts;  their  absorption  of  the  perspiration  and  other  excretions; 
the  frequent  necessity  of  renovating  them ;  the  aggravation  of 
these  effects  in  warm  weather,  in  corpulent  females,  and  in  labo- 
rious women.  The  perineal  band  or  pad  will  give  special  trouble, 
being  liable  to  many  sources  of  uncleanliness  and  consequent 
irritation. 

Hypotheses  of  their  Action. — Prepossessed  in  their  favor,  physi- 
cians have  made  so-called  scientific  attempts  to  justify  their  em- 
ployment of  these  external  supports  for  a  displaced  uterus.  No 
one  but  the  most  grossly  ignorant  could  imagine  that  the  uterus 
could  be  raised  up  by  the  compress  above  the  pubis — seeing  that 
all  such  pressure  is  above^  not  below  the  womb.  But  it  has  been 
very  universally  maintained  by  these  professional  advocates,  that 
the  pressure  on  the  hypogastric  region  elevated  the  intestines  so 
that  they  distended  the  upper  part  of  the  abdomen,  and  thus 
pressure  was  removed  from  the  uterus,  alloAving  its  natural  sup- 
ports to  regain  their  strength  and  contractility. 

This  is  a  strange  hypothesis  for  an  anatomist  or  a  mechanician 
to  make,  and  still  more  strange  for  the  natural  philosopher  and 
physiologist ! 

Is  not  the  so-called  cavity  of  the  abdomen  a  "plenum"?  Are 
not  the  small  intestines  movable  in  every  direction,  to  the  extent  of 
the  mesentery  ?  Do  they  not  readily  glide  wherever  there  is  a 
tendency  to  vacuity?  Is  there  not  always  a  steady  pressure  on 
the  viscera  from  the  walls  of  the  abdomen,  and  must  not  great 
pressure  be  made  to  bring  even  the  central  portion  of  the  mus- 
cular walls  of  the  abdomen  in  contact  with  the  spinal  column  ? 
Even  if  this  could  be  kept  up,  would  there  not  be  an  abundance  of 
space  for  the  intestines  to  glide,  each  side  of  the  lumbar  vertebrae, 
from  the  iliac  fossae  into  the  pelvis  ?  This  space  no  external  pres- 
sure could  possibly  obliterate.  If  the  lower  or  any  other  part  of 
the  abdomen  be  subjected  to  pressure,  would  not  all  the  viscera  be 
proportionally  compressed,  and  the  reaction  be  in  every  direction, 
not  merely  upwards  to  distend  the  epigastric  and  hypochondriac 
regions,  but  also  downwards  into  the  pelvis,  thus  increasing  the 
pressure  on  the  pelvic  viscera  ?  Is  not  all  this  supposed  upward 
pressure  of  the  intestines  resisted  by  the  liver,  spleen,  stomach, 


880      TREATMENT    OF    DISPLACEMENTS    OF    THE    UTERUS. 

and  diaphragm,  by  tlie  non-contractile  as  well  as  by  the  powerful 
contractile  tissues  of  the  abdomen  ?  Is  not  this  resistance,  from 
above,  constantly  increased,  and  sometimes  forcibly  augmented 
by  standing,  walking,  dancing,  straining,  coughing,  and  every 
conceivable  variety  of  muscular  exertion,  not  excepting  the  sim- 
ple natural  action  of  the  muscles  of  respiration  ?  Do  not  those 
women  who  wear  these  supporters  very  universally  counteract 
also  this  supposed  elevation  of  the  intestines  from  the  uterus,  by 
tight  ligatures  around  the  epigastric  and  lumbar  regions  to  which 
are  appended  some  eight  to  fifteen  pounds  weight  of  under-gar- 
ments?  Is  not  this  counteracting  influence  generally  augmented 
by  corsets,  laced  more  or  less  tightly,  and  by  fashionable  dresses, 
which  demand  the  strong  fingers  of  the  maid-in-waiting,  or,  it 
may  chance  be,  little  pulleys  and  strings,  to  insure  the  hooking 
of  the  dress  ?  Is  it  possible  to  conceive  that  any  pressure,  how- 
ever great  it  can  be  made,  at  the  lower  part  of  the  body,  will 
prevent  all  these  influences,  in  addition  to  the  gravity  of  the 
intestines,  and  the  continually  varying  size  of  the  alimentary 
canal  from  food,  gas,  and  feculent  accumulations?  "  Credat  alter, 
non  ego." 

As  regards  the  perineal  pad  or  supporter,  perhaps  more  can 
be  said  in  its  favor,  inasmuch  as,  in  cases  of  procidentia  uteri,  the 
organ  may  be  kept  within  the  vulva,  to  the  great  comfort  of  the 
patient ;  and  in  many  cases  the  upward  pressure  affords  compara- 
tive relief  to  the  sensations. 

It  has,  however,  and  can  have,  no  effect  in  relieving  any  of  the 
internal  displacements.  If  the  perineum  be  firmly  pressed  up- 
wards in  cases  oi prolapsus,  the  os  uteri  will  impinge  more  firmly 
on  the  posterior  wall  of  the  vagina,  by  which  any  flexion  of  the 
uterus  will  be  actually  increased,  and  the  symptoms  dependent 
thereon  be  augmented,  while  in  anteversion  or  retroversion  no  change 
of  position  can  possibly  result  from  this  upward  pressure. 

Mere  Palliatives. — From  what  has  been  said,  the  conclusion 
may  fairly  be  made,  that  external  supports  are,  at  best,  but  pal- 
liative as  regards  some  of  the  symptoms  of  displacement,  and 
that  they  have  no  tendency  to  restore  the  organ  to  its  proper 
position ;  but,  on  the  contrary,  that  the  whole  tendency  of  the 
abdominal  brace  is  to  aggravate  the  pressure  on  the  uterus,  and 
increase  its  deviations.     Hence  such  supporters  should  be  ena- 


ACTION    OF    BANDAGES.  381 

merated  among  the  causes,  original  or  aggravating,  of  uterine 
displacements,  and  not  among  the  remedies. 

This  view  is  confirmed  by  the  constant  experience  of  the 
author.  Few  patients,  for  some  years,  have  come  under  his  care 
in  which  these  bandages  have  not  been  used  for  a  longer  or  shorter 
time ;  yet,  in  all  cases,  the  displacement  was  found  still  existing, 
and  in  some  to  a  great  degree. 

Cases. — In  one  patient,  a  supporter  had  been  in  use  for  three 
years,  palliating,  to  be  sure,  many  symptoms  ;  bat  the  uterus  was 
so  completely  retroverted  that  its  posterior  surface  was  parallel 
to  the  internal  plane  of  the  perineum. 

In  another  lady,  who  had  suffered  excessively  from  dyspeptic 
and  cephalalgic  symptoms  for  nine  years,  and  was  regarded  as  a 
confirmed  invalid,  a  decidedly  retroverted  and  hypertrophied 
uterus  was  found  existing  in  spite  of  the  constant  use  of  a  sup- 
porter for  the  whole  of  this  long  period. 

Hoio  they  afford  relief. — In  answer  to  all  these  facts  and  reason- 
ing, the  question  is  urged :  if  these  supporters  do  not  elevate  the 
intestines,  and  if  they  so  decidedly  augment  the  downward  pres- 
sure on  the  pelvic  viscera,  how  can  so  many  patients  wear  them 
with  so  much  relief,  and  be  so  dependent  on  them  for  their  com- 
fort and  power  of  locomotion? 

There  is  a  twofold  answer  to  this  question,  and  to  the  mind  of 
the  author  perfectly  satisfactory,  as  well  as  in  unison  with  the 
daily  experience  of  patients  and  their  physicians. 

Certain  varieties  of  pain  and  morbid  sensations  are  relieved  hy 
pressure.  The  pain  of  a  bruised  finger  is  often  diminished  by 
even  a  firm  grasp ;  aching  sensations  in  the  back  and  limbs  are 
relieved  by  frictions  and  pressure.  What  woman,  liable  to  nerv- 
ous headaches,  who  has  not  found  relief  by  a  bandage  firmly  tied 
over  the  forehead  and  temples  ?  What  woman,  in  the  agonies  of 
childbirth,  has  not  called  for  a  powerful  support  to  her  aching 
back?  A  young  lady,  when  suffering  from  what  she  called 
universal  neuralgia,  expressed  great  delight  from  a  firm  grasp  of 
a  hand  around  her  arm.  Many  years  ago,  we  attended  a  lady  sub- 
ject to  the  most  intense  paroxysms  of  pain  in  the  chest,  lasting 
for  a  few  minutes,  and  often  alternating  with  a  similar  pain  in  the 
forehead.  During  the  paroxysm  of  pain,  she  would  call  for  the 
most  powerful  pressure  to  be  made  on  the  sternum  by  the  hands 
of  one  or  two  attendants.     As  soon  as  the  pain  ceased,  the  skin 


382      TREATMENT    OF    DISPLACEMENTS    OF    THE    UTERUS. 

became  so  sensitive,  that  the  weight  even  of  her  garments  was 
disagreeable ;  but,  in  a  few  moments,  on  the  return  of  pain,  the 
attendants  were  again  earnestly  called  upon  to  renew  the  pressure. 
The  same  operation  was  also  required  when  the  neuralgic  suffer- 
ing invaded  the  forehead. 

Thus  it  is,  in  cases  of  irritable  uterus,  the  miserable  sensations 
and  pain  in  the  back  and  abdomen  are  relieved  by  pressure  from 
the  hands  or  the  brace.  And  it  will  be  found  that  the  relief  is 
often  greater  from  pressure  over  the  sacral  region,  by  which,  of 
course,  no  support  can  be  given  to  the  internal  viscera.  In  one 
patient,  we  remember,  who.  although  she  could  not  tolerate  on  the 
hypogastrium  the  pad  of  a  brace,  as  the  tenderness  was  so  great, 
lamented  she  could  not  have  the  pressure  continued  over  the 
sacrum.  Even  while  in  bed,  many  patients  must  have  their  hand 
or  some  hard  body  pressed  upon  the  sacral  region  to  give  partial 
relief.  This  affords  one  solution  of  the  apparent  enigma  we  are 
explaining. 

The  second  answer  is  perhaps  still  more  satisfactory.  External 
pressure  increases  the  efficiency  of  muscular  action.  Every  reader  of 
the  Bible  is  familiar  with  the  ancient  practice  of  girding  up  the 
loins  for  the  race.  The  athletes  of  Greece,  the  runners  in  the 
Olympic  games,  following  the  example  of  their  predecessors,  are, 
in  turn,  universally  imitated  by  the  ambitious  ones  of  modern 
times,  who  aspire  for  victory  in  the  race  or  the  combat.  The 
huntsman's  girdle  is  but  a  counterpart  of  the  most  recherche 
of  utero-abdominal  supporters.  Many  a  young,  luxurious, 
fashionable  woman,  who  affirms  she  cannot  walk  a  step  or  even 
maintain  herself  in  a  sitting  posture,  without  her  corsets,  or  her 
tight  dresses,  will,  with  them,  dance  the  night  through,  without 
acknowledging  the  least  sensation  of  fatigue.  The  physiologist 
knows  the  importance  of  the  dense  fasciae  of  the  limbs  in  giving 
efficiency  to  the  muscles  which  they  cover;  and  the  surgeon, 
wisely  taking  the  hint  from  nature's  arrangements,  often  resorts 
to  bandages  and  other  measures  to  sustain  the  debilitated  muscles 
of  an  exhausted  patient. 

It  is  very  evident,  therefore,  that  abdominal  supporters,  by 
their  pressure  on  the  muscles  of  the  loins  and  abdomen,  will  often 
enable  weak  and  enervated  females  to  make  much  more  exertion 
than  they  otherwise  could  do.  Hence,  a  uniform  regular  pressure 
over  the  whole  parietes  of  the  abdomen,  of  a  moderate  character. 


ACTION    OF    BANDAGES,  383 

is  advantageous  in  cases  of  great  relaxation  and  debility  of  these 
tissues.  Most  accoucheurs,  therefore,  recommend  the  "  binder" 
to  women  after  delivery,  until  the  tissues  have  recovered  their 
elastic  and  contractile  powers.  Many  mothers  pursue  this  plan 
to  preserve  the  symmetry  of  their  figure,  after  parturition.  The 
surgeon  also  applies  his  bandages  to  the  abdomen  after  the  ope- 
ration of  paracentesis,  where  there  has  been  great  distension  from 
dropsical  effusions.  So,  in  many  cases  of  debility  of  these  mus- 
cular tissues,  a  moderate  compression  will  prove  useful,  not  only 
in  enabling  the  weak  to  endure  the  fatigue  of  long  walking, 
dancing,  etc.,  but  also  the  orator  to  exert  his  lungs,  or  the  vocalist 
her  voice  to  the  greatest  extent. 

No  wonder,  then,  women  often  are  anxious  to  wear  these 
braces,  and  praise  them  highly,  as  relieving  nervous  distresses, 
and  enabling  them  to  take  moderate  exercise.  Let  it  never, 
however,  be  forgotten,  that  all  such  pressure  is  at  the  risk  of 
depressing  the  uterus ;  and  that  the  idea  of  replacing  or  support- 
ing a  displaced  uterus  by  pressure  above  the  pubis,  must  be 
regarded  as  an  absurdity  in  physics,  and  deceptive  in  thera- 
peutics. 


8S4  TKEATMENT — INTERNAL    SUPPORTERS. 


CHAPTER   V. 

TREATMENT   OF    D  ISPL  A  C  EMENTS  — Continued.      INTERNAL 

SUPPORTERS. 

TiiEfou7-th  mode  of  treating  deviations  of  the  uterus,  deserving 
of  consideration,  is  tlie  employment  of  internal  supporters;  that 
is,  of  foreign  bodies  to  be  introduced  into  the  vagina,  and  so 
arranged  as  to  replace  the  uterus,  and  to  maintain  it  in  its  natural 
position.     Such  bodies  have  been  universally  termed  pessaries. 

Value  of  Pessaries. — Few  subjects  have  occupied  profes- 
sional attention  more  than  these  instruments,  and  in  few  instances 
have  the  opinions  of  practitioners  been  prone  to  more  vacillation. 
The  pessary  has  been  highly  extolled  at  one  time  or  by  one  set 
of  physicians ;  while  at  another  period,  or  by  another  set,  the 
most  severe  criticisms  have  been  poured  out  on  their  use,  as 
inefficient  and  dangerous.  Whence  these  extremes?  Doubtless 
it  is  owing  to  a  want  of  attention,  to  a  limited  experience,  and 
especially  to  an  absence  of  proper  scientific  principles  in  guiding 
and  regulating  the  practitioner  in  their  employment. 

The  long  experience  of  the  author  in  the  use  of  pessaries  will 
perhaps  justify  the  expression  of  his  opinion,  that  the  mechanical 
treatment  of  uterine  displacements  by  intra- vaginal  supports  is 
essential,  a  "sine  qua  non,"  for  their  perfect  relief;  that  by  pes- 
saries of  suitable  material,  size,  and  form,  the  uterus  may  very 
generally  be  replaced  and  be  maintained  in  situ ;  that  the  local 
symptoms  of  weight,  pain,  etc.,  the  leucorrhoea,  the  monorrhagia, 
the  dysmenorrhoea,  and  all  the  innumerable  direct  and  indirect 
symptoms  of  spinal  and  cerebral  irritation,  including  neuralgia, 
nervous  headache,  nervous  affections  of  the  larynx,  lungs,  heart, 
stomach,  bowels,  etc.,  as  also  spasms,  cramps,  and  convulsions, 
may  often  thus  be  dissipated ;  that  the  intellectual  and  spiritual 
being  may  be  elevated  from  the  lowest  states  of  depression,  bor- 
dering on  melancholy,  or  be  delivered  from  the  highest  degree 


TEUE    VALUE    OF    PESSARIES.  885 

of  maniacal  excitement ;  and  that  the  whole  economy  may  thus 
be  revolutionized.  Patients  often  are  amazed  at  their  own  altered 
sensations ;  they  can  hardly  realize  their  identity — feeling  as  if 
they  were  either  renovated,  or  that  they  had  been  transported  to 
a  "  new  world." 

This  will  doubtless  be  regarded  as  very  extravagant — as  the 
language  of  an  enthusiast ;  but  the  author  has  merely  recorded 
the  expressions  of  many  of  his  patients  who  have  been  relieved  ; 
but  he  would  by  no  means  wish  to  convey  the  idea  that  sucli 
ecstatic  feelings  are  universal.  He  is,  by  painful  experience, 
fully  aware  that  here,  as  in  all  other  cases,  disappointments  will 
occur;  that  partial  relief  only  is  sometimes  afforded;  and  that 
great  patience,  with  often  long  perseverance  in  the  scientific  use 
of  appropriate  measures,  may  be  requisite.  Yet,  he  feels  per- 
fectly confident  that  when,  by  mechanical  measures,  displacements 
of  the  uterus  are  completely  relieved,  and  when  the  agents  them- 
selves excite  no  irritation,  such  results  may  be  anticipated.  The 
difiiculties  arise  from  the  improper  character  of  the  instruments 
employed,  the  mechanical  obstructions  to  a  replacement  of  the 
organ,  the  great  sensibility  of  the  vital  tissues  involved,  the 
timidity  and  nervousness  of  the  patient,  and  too  frequently  the 
want  of  proper  indications  in  carrying  out  the  treatment.  Ex- 
perience proves  that  these  obstacles  are  great :  they  have  hitherto 
defied  the  efforts  of  physicians,  as  proved  by  the  discrepancies  of 
opinion  on  all  these  points,  and  by  the  numerous  varieties  and 
modifications  of  pessaries  suggested  by  the  ingenuity  of  their 
advocates,  who  have  not  even  yet  satisfied  themselves.  Much, 
doubtless,  is  to  be  done,  but  science  and  ingenuity,  with  careful 
attention  and  perseverance,  may  soon  render  recoveries  rapid 
and  easy  where  difficulties  now  seem  to  be  almost  insur- 
mountable. 

Objections  to  Pessaeies. — Great  objections,  however,  exist 
and  are  urged  against  the  use  of  all  these  internal  supports, 
which  must  be  carefully  examined,  so  as  to  present  the  subject 
fully  before  the  mind  of  the  practitioner. 

Pessaries  are  condemned  by  many  as  exciting  pain,  irritation, 
and  inflammation,  followed  by  increased  watery  or  mucoid  secre- 
tions, and  purulent  discharges,  often  of  a  bad  and  putrid  charac- 
ter, by  ulcerations  of  the  os  uteri  and  of  the  vagina,  which 
25 


386       TREATMENT — INTERNAL  SUPPORTERS. 

ulcerations  are  said  to  have  penetrated  the  bladder,  the  rectum, 
and  even  the  cavity  of  the  peritoneum.  Of  course,  in  such  cases, 
the  pain  and  sufferings  of  the  patient  are  augmented,  emaciation 
and  fever  may  be  excited,  and  even  the  life  of  the  patient  in- 
volved. Such  is  the  language  of  the  opponents  of  pessaries;  but 
certainly  these  bad  consequences  must  be  numbered  among  the 
abuses  of  the  instrument,  rather  than  its  legitimate  results.  If 
the  same  mode  of  reasoning  be  applied  to  any  of  the  powerful 
articles  of  the  Materia  Medica,  such  as  mercury,  arsenic,  prussio 
acid,  opium,  ether,  or  chloroform,  the  mischievous  influences  of 
these  valuable  agents  for  alleviating  human  suffering  would 
appear  to  be  well  established.  "We  cannot  argue  against  the  use 
of  a  thing  from  its  abuse. 

The  evils  attributed  to  these  instruments  arise  chiefly  from 
three  sources,  namely,  from  the  material,  form,  and  size  of  the 
instrument. 

The  improper  character  of  the  material  employed  in  their  con- 
struction is  a  frequent  source  of  trouble.  Any  article  capable  of 
decomposition  should  not  be  allowed  to  remain  in  the  vagina, 
where  there  is  always  heat,  moisture,  and  atmospheric  air,  so  that 
disintegration  of  such  a  pessary  speedily  ensues;  whence  acrid 
and  putrid  discharges  and  inflammation  necessarily  follow. 
These  natural  results  are  often  enhanced  by  the  vaginal  and  ute- 
rine secretions,  which  seem  to  have,  to  some  extent,  a  corroding 
power. 

The  second  source  of  mischief  is  the  form  of  the  instruments. 
Frequently  they  are  constructed  with  thin  edges,  angular  projec- 
tions, points,  or  other  inequalities;  also  some  have  perforations, 
into  which  the  neck  of  the  uterus  or  the  mucous  membrane  of 
the  vagina  projects;  or  they  are  furnished  with  a  stem,  which, 
projecting  out  of  the  body,  not  merely  renders  the  instrument 
fixed  with  an  unyielding  pressure  on  the  tissues,  but  aggravates 
the  irritation,  especially  at  the  orifice  of  the  vagina  and  the  vulva. 

A  third  source  of  discomfort,  and  a  very  frequent  one,  arises 
from  inordinate  pressure,  either  from  the  too  great  size  or  power  of 
the  instrument,  or  from  its  pressing,  in  an  improper  direction,  too 
firmly  on  particular  portions  of  the  uterus  or  vagina;  whence,  of 
course,  inflammation,  ulceration,  etc.,  follow. 

In  all  cases  it  has  been  a  matter  of  surprise  to  the  author  to 
find  with  what  rapidity  fetid  discharges,  inflammations,  and  even 


OBJECTIONS    TO    PESSARIES.  387 

ulcerations  of  the  uterus  and  vagina,  vanish  on  the  removal  of 
the  cause,  and  the  use  of  detergent  and  astringent  washes.  In  a 
few  days  their  bad  effects  are  usually  dissipated. 

There  can  be  little  doubt  but  that,  by  care  and  attention,  all 
these  objections  to  the  pessary  can  be  obviated.  The  important 
declaration  may  be  safely  made,  that  pessaries  can  be  worn  for 
many  months,  not  merely  with  impunity,  but  with  great  advan- 
tage, keeping  the  organ  in  its  natural  position,  relieving  the 
symptoms  of  displaced  and  irritable  uterus,  the  terrible  irritations 
of  the  cerebro-spinal  system,  and  allowing  the  bedridden  and  nerv- 
ous patient  to  exert  again  her  powers  of  locomotion  and  resume 
the  duties  of  her  social  position,  without  any  local  disturbance  or 
uneasiness.  She  finds  herself  relieved  without  being  conscious 
of  the  presence  of  the  agent  by  which  she  is  benefited.  A  vagi- 
nal injection  of  pure  water  every  day  is  almost  the  only  attention 
required.  We  are  abundantly  satisfied  that  these  bright  hopes 
may  be  realized  by  the  scientific  employment  of  suitable  pessaries. 
The  difficulties  may  be  great,  and  the  means  of  success  perhaps 
imperfect ;  but  there  is  no  doubt  in  the  author's  mind  that  proper 
indications  can  be  established,  and  that  human  ingenuity,  in 
unison  with  skill  and  patient  perseverance,  will  insure  a  success 
which,  to  the  minds  of  many,  may  now  be  deemed  Utopian. 

IxDiCATioxs  TO  BE  FULFILLED. — More  particularly  it  may  be 
urged  that  a  pessary  should  be  made  of  incorruptible  materials. 
It  should  restore  and  maintain  the  uterus  in  its  normal  position 
at  all  times,  under  the  ever-varying  pressure  from  above.  It 
should  be  movable  with  the  uterus,  allowing  of  the  natural  mo- 
tions of  this  organ,  yet  effectually  preventing  any  displacement. 
It  should  be  one  with  the  uterus.  It  should  be  worn  without 
pain,  uneasiness,  or  discomfort,  indeed,  without  any  consciousness 
on  the  part  of  the  patient.  It  should  relieve,  and  not  increase, 
nervous  irritations.  It  should  excite  no  organic  or  vascular  dis- 
turbance, no  engorgement,  no  inflammation;  and,  therefore,  it 
should  be  influential,  not  in  increasing  leucorrhoeal  and  menor- 
rhagic  discharges,  but,  under  proper  restrictions,  as  will  be  demon- 
strated, in  contributing  to  the  resolution  of  chronic  inflammations 
of  the  OS  and  cervix  uteri. 

Material. — The  first  requisite,  therefore,  in  a  suitable  internal 
supporter,  is  incornqjtihi'ity  of  the  material  of  which  it  is  made. 


388       TREATMENT  —  INTERNAL  SUPPORTERS. 

The  instrument  ought  to  be  worn  for  months,  and  even  for  years. 
The  decomposition  of  the  material  would,  of  course,  be  incom- 
patible with  this  necessity,  as  the  frequent  removal  and  replacing 
of  a  pessary  is  a  subject  of  annoyance  and  irritation,  mental  as 
well  as  physical,  and  as  the  discharges,  becoming  unpleasant,  fetid, 
and  irritating,  produce  internal  and  external  inflammation. 

The  numerous  suggestions  of  employing  wood^  cork,  wax,  sponge, 
hair,  ivory,  horn,  cotton,  and  even  the  preparations  of  gum-elastic 
or  of  gutta-percha,  that  have  been  ordinarily  employed,  should  be 
entirely  disregarded.  Many  of  these  vegetable  and  animal  sub- 
stances imbibe  and  retain  the  natural  secretions,  which  then  in  a 
few  hours  or  days  become  excessively  fetid  and  irritating ;  while 
all  these  materials,  if  retained,  are  liable  to  decompose  in  a  longer 
or  shorter  period,  and  thus  become  intolerable. 

This  observation  is  true  of  gutta-percha,  which  has  been  highly 
extolled  and  extensively  employed;  some  of  the  most  offen- 
sive pessaries  we  have  ever  removed  have  been  of  this  material, 
too  offensive  to  be  tolerated  in  the  room  after  their  extraction 
from  the  vagina.  Occasionally  this  decomposition  has  been  so 
great  as  to  injure,  to  a  destructive  extent,  the  steel  spring  and  its 
envelop  of  cotton  thread,  which  gave  firmness  to  the  instrument. 
This  is  the  fact ;  the  explanation  of  it  was  not  at  first  apparent, 
for  gutta-percha  is  considered  to  be  one  of  the  most  incorruptible 
of  materials.  Yet  it  should  be  remembered  that  though  it  resists 
the  action  of  the  strong  acids,  it  softens  at  once  in  warm  water. 
In  the  vagina  we  have  heat  and  moisture  always  present ;  these, 
with  the  pressure  to  which  the  pessary  is  subjected,  no  doubt 
soften  and  attenuate  the  gutta-percha,  so  that  the  secretions  pene- 
trate to  the  steel  spring,  corrode  it,  percolate  between  it  and  the 
gutta-percha,  and  putrefy.  Perhaps,  also,  some  chemical  change, 
besides  mere  solution,  is  produced  in  the  gutta-percha  by  the 
chloroform  employed  in  the  manufacture  of  these  instruments, 
or  by  the  acid  secretion  of  the  vagina. 

Iron,  steel,  silver,  and  German  silver  oxidize  rapidly  in  the  vagina. 
Pure  tin  oxidizes  slowly,  and  can  be  worn  for  a  long  time  without 
alteration.  Mr.  John  Warner,  our  instrument-maker,  employs 
a  cheap  material  of  tin,  zinc,  and  lead,  which  answers  for  a  time, 
but  should  not  be  trusted  in  patients  who  cannot  be  frequently 
seen. 

Perhaps  one  of  the  best  articles  is  glass,  which  has  been  very 


MATERIAL.  389 

commonly  used  in  the  form  of  globular  and  disk,  or  concavo- 
convex  pessaries ;  yet,  in  many  instances,  the  polished  surface 
of  the  glass  has  been  entirely  destroyed,  so  that  it  has  become 
opaque  and  rough  like  ground  glass.  Glass,  however,  cannot  be 
moulded  so  as  to  be  safely  employed  in  the  various  shapes  that 
are  requisite,  and  women  are  generally  timid  as  to  its  use.  Be- 
sides, globe  pessaries  of  this  material,  unless  very  thick,  cannot 
always  be  removed  from  the  vagina  without  risk  of  a  fracture. 

Porcelain  pessaries  would  prove  equally  indestructible,  but  are 
too  heavy  when  spherical  or  elliptical ;  and  as  regards  the  most 
desirable  form,  the  artisans,  that  we  have  employed,  have  failed 
in  their  manufacture. 

Platina  and  gold  are  perhaps  the  only  metals  suitable  for  prac- 
tical purposes.  The  former,  from  its  weight  and  expensive  cha- 
racter, has  been  seldom  used ;  but  gold  has  been,  at  least  in  this 
country,  very  extensively  used,  especially  as  a  covering  for  silver. 
The  expense  has  been  too  great  for  the  employment  of  the  pure 
metal,  and  even  the  silver-gilt  pessary  costs  too  much  for  general 
use.  It  is  almost  the  only  material,  till  lately,  that  we  have  de- 
pended upon.  AYe  have  had  patients  who  have  worn  silver-gilt 
pessaries  for  five  and  occasionally  for  nine  years,  without  any 
bad  consequences.  Nevertheless,  the  gold  will  wear  off;  in  some 
instances,  after  a  long  time,  it  will  be  acted  on  by  the  acridity  of 
the  menstrual  and  leucorrhoeal  discharges ;  and  not  unfrequently 
it  becomes  tarnished,  even  when  the  coat  of  gold  is  intact.  There 
can  be  no  doubt  that,  with  some  patients,  owing  to  peculiarities 
of  their  secretions,  the  gold  disappears  with  comparative  rapidity, 
while  in  others,  after  the  lapse  of  years,  no  alteration  has  ensued. 
The  remark  may  be  here  made,  that  instruments  are  often  said  to 
be  corroded,  when  no  injury  has  been  sustained;  deposits  of  mucus 
and  of  m.enstrual  fluids  accumulate,  particularly  where  daily 
vaginal  washes  have  not  been  employed,  dry,  incrust  the  instru- 
ment, and  make  it  rough  and  even  irritating.  In  some  instances, 
particularly  in  bedridden  patients,  calcareous  deposit  has  been 
found  on  the  pessary,  as  if  the  urine  had  settled  into  the  vagina, 
and  its  salts  deposited. 

There  is,  however,  another  substance  of  great  value;  it  is  a 
comparatively  new  preparation  of  caoutchouc,  brought  into  use 
and  patented  by  Goodyear,  the  celebrated  manufacturer  of  this 


390       TREATMEXT  —  IXTERXAL  SUPPORTERS. 

article.  It  is  commonly  termed  '■''hard  hvlla-riLbher^''  or  '■^hard 
vulcanite^''''  and  has  been  worked  up  into  many  useful  articles, 
such  as  syringes,  combs,  pencils,  fountain-pens,  rings  for  harness, 
etc.,  and  is  represented  as  being  incapable  of  decomposition,  and 
able  to  resist  the  action  of  concentrated  acids  and  the  most  power- 
ful chemical  reagents.  The  experiments  that  we  have  made  with 
this  article  for  pessaries  have  been  very  favorable;  no  perceptible 
change  has  been  manifested  in  the  integrity  of  the  ring  after 
being  worn  for  years,  even  in  cases  where  leucorrhoea  existed. 
The  smooth,  polished  surface  has  not  been  altered  even  when  it 
has  been  covered  with  diYj  mucoid  deposits.  It  is,  therefore,  a 
cheap  and  excellent  material  for  such  agents.* 

f  Form  of  the  Instrument. — Many  of  the  various  shapes 
'  suggested  for  these  instruments  have  proved  so  inefficient  and 
objectionable,  that  they  have  been  successively  discarded  by 
large  numbers  of  the  profession ;  and  many  practitioners  have 
even  entirely  abandoned  the  use  of  pessaries.  Let  it  be  observed, 
however,  that  different  patients,  from  peculiar  modifications  of  the 
displacement,  or  certain  complications,  may  demand  not  merely 
supporters  of  various  power,  but  of  diverse  shapes,  to  fulfil  the 
indications.  A  very  mistaken  idea  is  prevalent,  that  a  pessary  is 
merely  to  be  pushed  into  the  vagina  by  the  physician,  the  nurse, 
or  the  patient,  and  left  to  fix  its  own  position,  to  replace  the  organ, 
and  to  afford  permanent  relief.  Hence,  physicians  sometimes, 
without  even  a  vaginal  examination,  have  handed  an  instrument 
to  the  sufferer,  and  requested  her  to  operate  on  herself,  altogether 
regardless  of  the  kind  of  displacement,  the  proper  form  or  even 
the  size  of  the  pessary  employed.  No  wonder  that  such  practice 
has  been  ineflEicient,  and  that  bad  consequences  have  followed ! 
I  The  introduction  of  the  instrument  should  be  made  with  care, 
and  its  adjustment  often  requires  much  time  and  patience ;  indeed, 
the  complete  reposition  of  the  organ  in  cases  of  long  standing, 
where  the  tissues  are  accommodated  to  their  unnatural  position, 
or  when  tumors,  adhesions,  or  other  impediments  exist,  may  be 

'  Eight  sizes  of  our  closed-lever  pessaries  have  been  made  of  this  material.  They 
may  be  obtained  from  the  American  Hard-Rubber  Co.,  or  the  surgical  instrument- 
makers,  J.  H.  Gemrig,  No.  109  S.  Eighth  Street,  D.  W.  Kolbe,  No.  15  S.  Ninth  Street, 
and  others. 


GLOBULAR.  391 

the  work  of  weeks  or  even  months,  requiring  pessaries  of  varied 
forms  and  power.  Eeplacement  can  thus  be  gradually  accom- 
plished, even  in  cases  apparently  desperate.  In  many  cases  of 
chronic  retroversion  of  the  uterus,  even  without  but  especially 
with  flexion,  time  is  demanded  to  fulfil  the  important  indication 
to  move  the  fundus  uteri  from  its  depression  near  the  coccyx, 
along  the  cavity  of  the  sacrum,  to  its  legitimate  position  behind 
the  bladder,  and  among  the  small  intestines.  , 

All  pessaries  should  be  perfectly  smooth  and  even  polished,  so 
as  to  facilitate  their  introduction,  and  not  allow  any  adhesion  of 
the  mucoid  fluids  to  their  surface.  They  should  not  be  very 
thin,  as  they  would  press  too  much  into  the  tissues  and  be  apt  to 
induce  inflammation.  They  should  always  be  free  from  irregu- 
larities and  angular  projections,  lest  they  should  produce  u.ndue 
pressure. 

It  will  be  profitable  to  review  the  most  important  forms,  which 
have  been  proposed  for  the  relief  of  displacements  of  the  uterus, 
and  to  present,  with  all  candor,  their  respective  advantages  and 
disadvantages.  The  object  of  the  writer  is  truth  and  the  relief 
of  human  suffering;  hence,  the  objections  and  dangers  of  the 
varieties  suggested  by  the  author,  as  well  as  those  proposed  by 
others,  will  be  detailed,  even  while  recommending  their  trial  to 
his  professional  brethren. 

Globular  Pessaries. — The  globular  or  spherical  pessary  has 
apparently  much  to  recommend  it,  as  being  perfectly  smooth, 
without  angles  and  edges,  and  as  demanding  no  special  adjust- 
ment after  introduction.  It  has  been  highly  spoken  of  by  dis- 
tinguished men,  and  at  one  time  was  regarded  by  many  as  perfect 
in  its  influences.  Now,  however,  it  has  greatly  fallen  into  disuse, 
and  apparently,  justly.  A  small  ball  is  perfectly  useless,  while 
one  large  enough  to  be  retained  requires  considerable  force  and 
pain  to  introduce,  and  even  then  is  seldom  of  sufficient  size  to  be 
useful.  If  retained,  a  globular  pessary  almost  always  rests  at  the 
lower  extremity  of  the  vagina,  under  the  urethra,  and  in  front  of 
the  inferior  portion  of  the  rectum.  It  keeps  up  a  disposition  to 
urinate,  and  frequently  a  tenesmus,  particularly  after  the  bowels 
are  moved. 

The  support  that  it  affords  to  the  uterus  in  anteversion,  is 
sometimes  very  good,  indeed,  all  that  is  required,  and  to  such 


392  TEEATMENT — INTERNAL    SUPPORTERS. 

cases,  it  is  best  adapted.  In  prolapsus  uteri,  it  cannot  be  de- 
pended upon.  In  one  case  only  have  we  ever  found  it  to  answer, 
and  then  the  ball  had  fortunately  made  a  lodgment  at  the  side  of 
the  cervix  uteri.  But  ordinarily,  in  prolapsus,  it  lies  in  front  of 
the  uterus,  and  therefore  can  give  it  no  support ;  and  the  organ 
descends  behind  the  pessary  on  the  posterior  wall  of  the  vagina. 
In  some  cases,  we  have  found  the  lower  part  of  the  cervix  uteri 
pressed  under  the  globe,  so  that  the  anterior  surface  of  the  organ 
was  rendered  concave  by  the  convexity  of  the  pessary,  consti- 
tuting a  prolapsus  with  flexion  ;  the  pessary  had  actually  aggra- 
vated all  the  symptoms  of  uterine  irritation.  In  retroversion  of 
the  uterus,  the  globular  pessary,  so  far  from  being  useful,  is  posi- 
tively injurious.  It  unavoidably  gets  behind  and  beneath  the 
cervix,  which  is  thus  turned  more  and  more  upwards,  while  the 
fundus  necessarily  sinks  lower  in  the  cavity  of  the  sacrum,  in- 
creasing the  pain  and  aggravating  all  the  symptoms  of  irritable 
Titerus.  In  procidentia  uteri,  the  ball,  if  very  large,  may  possibly 
be  retained,  and  prevent  the  external  projection  of  the  organ, 
although  it  will  not  ever  return  it  to  its  proper  position.  But 
very  universally,  the  ball,  owing  to  the  laxity  of  the  vulva  and 
vagina,  will  even  fall  out  almost  as  rapidly  as  it  is  introduced. 

The  introduction  of  ball  pessaries  is  easy  to  the  practitioner, 
but  generally  painful  to  the  patient ;  because  an  instrument 
comparatively  large  as  respects  the  orifice  of  the  vagina,  is  re- 
quisite that  it  may  be  retained  and  give  sufficient  support  to  the 
uterus. 

The  patient  should  be  placed  directly  on  her  back;  then  the 
vulva  and  the  pessary  being  anointed,  and  the  labia  separated, 
the  ball  is  to  be  pressed  slowly  and  steadily  into  the  orifice  of 
the  vagina  in  the  direction  of  the  axis  of  that  canal,  so  as  to 
stretch  the  posterior  margin  of  the  vulva,  and  make  as  little 
pressure  as  possible  on  the  urethra. 

The  removal  of  the  instrument  can  often  be  accomplished  by 
the  bearing-down  efforts  of  the  patient,  more  readily  than  by  the 
practitioner.  "When,  however,  from  the  large  size  of  the  globe, 
this  is  impracticable,  the  removal  can  be  accomplished  hj  suitable 
instruments ;  a  pair  of  placental  forceps  may  sometimes  be  requi- 
site, but  the  most  simple  and  ef&cient  instrument  is  a  small 
curved  lever,  a  drawing  of  which  is  given,  diminished  to  half  its 
size.     The  practitioner  can  now  extract  the  ball  by  introducing 


GLOBULAR.  393 

tlie  lever  behind  the  pessary,  and  supporting  its  opposite  side 
with  his  finger. 


Similar  observations  apply  with  more  or  less  truth  against 
every  modification  of  the  spherical  pessary,  such  as  the  hemi- 
sjyherical,  the  egg-shaped^  the  barrel- shaved,  the  conical,  and  the 
cylindrical,  whether  short  or  long  cylinders.  They  all  may  be 
occasionally  useful  in  special  cases ;  but  in  the  usual  forms  of 
displacement,  they  are  useless  or  injurious.  They  occasionally 
prove  useful,  as  adjuncts,  to  increase  the  power  of  other  forms  of 
these  instruments.  We  have  found  them  advantageous  in  ele- 
vating the  womb,  whether  simply  enlai'ged  or  complicated  with 
tumors,  which  occupied  the  cavity  of  the  pelvis,  pressing  on  the 
bladder,  rectum,  or  nerves  of  the  pelvis,  and  thus  exciting  the 
severe  symptoms  of  irritation.  We  have  succeeded  in  elevating 
these  masses  out  of  the  cavity  of  the  pelvis  to  the  great  and  per- 
manent relief  of  the  patient,  by  gradually  distending  and  enlarg- 
ing the  vagina  by  one  cylindrical  or  globular  pessary  after 
another.  This  object  being  accomplished,  the  pessaries  were 
removed,  and  the  enlarged  uterus  remained  suspended  on  the 
brim  of  the  pelvis,  like  the  uterus  after  "quickening,"  in  gesta- 
tion. 

The  introduction  and  removal  of  these  pessaries  can  be  accom- 
plished in  the  manner  already  described  for  the  globe.  In  the 
use  of  the  lever,  for  the  removal  of  cylindrical  pessaries,  however, 
some  care  will  be  necessary  in  fixing  the  lever  upon  one  ex- 
tremity of  the  cylinder,  so  that  the  instrument  shall  not  become 
transverse,  and  thus  interfere  with  its  easy  removal. 

Concavo-  Convex  Pessaries. — The  concavo-convex  pessary  with  a 
central  opening — the  flat  circular  disk — the  saucer-like  pessary — 
or  perhaps  best  known  in  this  country  as  Dewees'  pessary,  having 
been  strongly  recommended  and  employed  by  the  late  Prof. 
Dewees,  of  this  city,  has  been  very  extensively  resorted  to  in  the 
United  States,  and  so  successfully  that  its  supremacy  for  many 
years  was  undoubted.  There  were  but  few  practitioners  who 
did  not  depend  on  this  disk. 


394       TREATMENT  —  INTERNAL  SUPPORTERS. 

It  answers  very  well  in  anteversion  and  prolapsus  of  the 
uterus ;  and  in  procidentia  uteri  it  is  perhaps  still  superior  to 
any  other  pessary,  as  in  this  respect  it  has  the  advantage  even 
over  the  varieties  of  the  ring  in  distending  and  supporting  the 
relaxed  vagina,  so  as  to  prevent  its  descent,  as  well  as  that  of  the 
uterus.  In  such  cases,  we  still  often  employ  it.  In  retroversion 
of  the  uterus,  it  can  at  best  merely  palliate.  It  diminishes  the 
degree  of  retroversion,  but  cannot,  unless  perhaps  when  very  large, 
restore  the  fundus  to  its  natural  position.  The  reason  is  evident. 
The  convex  portion  of  the  pessary  rests  on  the  perineum,  an 
inclined  plane  from  the  vulva  to  the  coccyx.  The  edge  of  the 
pessary  will  always  be  felt  at  the  orifice  of  the  vagina  during  all 
the  straining  efforts  of  the  patient,  and,  of  course,  the  upper  edge 
or  opposite  portion  of  the  circumference  does  not  rise  so  as  to 
elevate  the  depressed  fundus  uteri.  This  margin  of  the  disk  and 
the  fundus  of  the  uterus  remain  in  the  hollow  of  the  sacrum.  A 
partial  retroversion  will  still  exist  to  torment  the  patient. 

Although  these  pessaries  may  be  so  frequently  useful,  and 
have  been  so  extensively  employed,  yet  they  have  deservedly 
fallen  into  much  disuse.  Their  inefficiency  in  the  common  case 
of  retroversion  has  greatly  contributed  to  this  result,  but  there 
are  other  serious  objections  to  their  general  use. 

Much  inconvenience  results  from  the  complete  occupation  of 
the  vagina,  and  still  greater  from  the  retention  of  fluids  chiefly 
between  the  uterus  and  the  concave  or  saucer- like  surface,  where 
they  putrefy  and  become  irritating  and  offensive.  The  idea  that 
these  fluids  would  be  discharged  through  the  circular  foramen  in 
the  centre  proved  fallacious ;  the  posterior  surface  of  the  vagina 
pushes  into  and  acts  as  a  perfect  stopper  to  this  opening.  The 
extremity  of  the  cervix  always  rests  firmly  on  the  concave  or 
superior  surface  of  the  pessary,  so  that  flexion  is  augmented,  the 
mucous  membrane  of  the  os  is  irritated,  or  inflamed,  and  some- 
times a  fungoils  growth,  by  the  pressure  of  a  lip  of  the  os  uteri 
into  the  orifice  of  the  pessary,  is  generated.  Such  fungous  gra- 
nulations we  have  known  project  also  from  the  posterior  vaginal 
surface  into  the  opening.  The  uncleanliness  of  the  instrument, 
and  these  inflammatory  effects  frequently  resulting,  conjoined 
with  its  inadequacy  to  relieve  retroverted  or  retroflexed  uteri, 
justify  its  almost  entire  abandonment. 

The  introduction  of  concavo-convex  pessaries  is  easily  accora- 


CONCAVO-COXVEX  —  PLANO-CONVEX,  895 

plished  by  separating  the  labia  and  pressing  the  instrument  ob- 
liquely, so  that  one  edge  is  to  the  left  of  the  urethra,  and  the  oppo- 
site side  to  the  posterior  margin  of  the  vulva  a  little  on  the  right. 
The  pessary  must  now  be  pushed  downwards  and  backwards,  the 
patient  being  on  her  back,  in  the  direction  of  the  axis  of  the 
vagina,  taking  care  that  it  assumes  the  transverse  position  after 
its  introduction,  so  that  the  concavity  shall  be  towards  the  uterus. 

The  removal  is  effected  by  placing  the  finger  on  the  concave 
surface  of  the  disk,  thus  making  firm  pressure  against  the  walls 
of  the  vagina,  and  taking  care  that  the  instrument  passes  ob- 
liquely through  the  orifice  of  the  vagina. 

If  any  difiiculty  be  experienced  from  the  size  of  the  pessary, 
or  the  contraction  of  the  orifice  of  the  vagina,  a  hook,  as  repre- 
sented in  the  diagram  at  the  extremity  of  the  small  lever,'  may 
be  passed  into  the  opening  in  the  centre  of  the  pessary,  by  which 
traction  can  be  efficiently  made. 

Piano- Convex  Pessaries. — "We  have  made  some  experiments 
with  a  plano-convex  pessary,  and  find  it  adapted  to  some  cases  of 
greatly  relaxed  vagina  with  or  without  procidentia,  to  displace- 
ments of  the  ovaries,  as  well  as  of  the  uterus,  where  there  is  much 
enlargement,  etc.  Its  only  advantage,  however,  over  Dewees' 
pessary  is,  that  it  is  more  cleanly,  as  the  fluids  are  not  so  much 
retained,  and  there  is  less  irritation  to  the  os  uteri;  but  otherwise 
it  is  liable  to  most  of  the  objections  of  the  concavo-convex  pes- 
sary. 

The  modifications  of  this  form,  with  surfaces  more  or  less  flat, 
and  edges  varying  in  thickness,  have  been  very  numerous ;  hence 
we  have  i\\Q  flat  oval  pessary,  the  ellij^tical^  the  long  plano-convex 
(a  longitudinal  cylindrical  section),  also  the  flattened  cylinder  (a  long- 
pessary,  say  three  inches,  with  the  extremities  and  transverse  sec- 
tion elliptical),  which  is  said  to  be  an  exact  mould  of  the  vagina, 
and  so  also  the  spoon-shape  pessary,  the  extremity  being  straight 
or  even  a  little  concave.  In  practice,  all  these  are  very  ineffi- 
cient ;  and  are  not  comparable  to  the  circular  disk,  which,  always 
presenting  the  same  diameters,  cannot  be  displaced ;  while  the 
others  press  irregularly,  and  their  long  diameter  will  never  remain 
parallel  to  the  length  of  the  vagina,  but  becomes  either  oblique 
or  directly  transverse,  doing  little  or  no  good.     Indeed,  those 

'  See  diagram,  p.  393. 


396       TREATMENT — INTERNAL  SUPPORTERS. 

who  have  patronized  them  seem  to  hav^e  had  no  other  jdea  than 
merely  to  push  the  orifice  of  the  uterus  away  from  the  vulva 
and  perineum,  regardless  of  the  position  of  the  fundus,  or  the 
direction  of  the  axis  of  the  organ.  The  transverse  position  of 
the  pessary  must,  it  would  seem,  have  been  considered  desirable, 
as  in  some  of  these  elliptical  or  long  pessaries,  the  sides  have 
been  made  concave  to  accommodate  the  urethra  and  the  rectum. 
Many  of  them  also  are  perforated  in  the  centre  ;  the  flat  cylindrical 
one  has  a  canal  through  its  whole  length,  under  the  vain  notion 
of  facilitating  the  discharge  of  fluids,  but  really  proving  a  source 
of  irritation,  as  the  tissues  press  into  the  openings,  and  the  dis- 
charges accumulating  become  putrid.  Many  other  modifications 
have  been  suggested  ;  but  all  are  liable  to  the  same  objections,  and 
especially  on  account  of  the  constant  pressure  they  make  on  the 
delicate,  irritable,  and  sensitive  tissues  of  the  os  and  cervix  uteri. 

"  Zwanc'ke'' s'''  or  the  "  Butterfly  Pessary ^^''  which  is  much  used  in 
Germany  and  also  in  Britain,  has  also  attracted  some  attention  on 
this  side  of  the  Atlantic.  It  consists  of  two  wings,  fenestrated, 
representing  the  section  of  an  oval,  being  comparatively  large  at 
one  end,  and  tapering  to  the  other ;  very  analogous,  although 
much  smaller,  to  the  blades  of  Smellie's  forceps.  The  small  ex- 
tremities are  connected  with  a  hinge,  and  are  prolonged  into  short 
handles,  which  decussate  each  other ;  so  that  when  they  are  ap- 
proximated, the  wings  are  separated ;  and  when  the  handles  are 
separated  the  wings  are  approximated.  This  movement  in  the 
handles  is  ingeniously  determined  by  a  screw  in  the  form  of  a 
small  button,  and  perfectly  smooth.  The  alie,  or  wings,  being 
brought  together,  are  introduced  deeply  into  the  vagina,  and  by 
turning  the  button  are  made  to  separate,  so  as  to  distend  the 
vagina  laterally,  making  no  pressure  against  the  uterus.  The 
removal  is  effected  by  causing  the  wings  to  approach  each  other 
by  reversing  the  action  of  the  screw.  The  whole  operation  is  so 
simple,  that  it  is  said  women  can  execute  it  at  pleasure. 

We  have. had  no  personal  experience  with  this  instrument,  but 
good  practitioners  speak  of  it  favorably  in  cases  of  great  relaxa- 
tion of  the  vagina,  with  procidentia  uteri,  etc.  The  objections 
which  suggest  themselves  to  our  miud  are  the  constant  irritation 
which  must  arise  from  the  presence  of  the  bulb  at  the  orifice  of 
the  vagina,  and  also  the  occupation  of  this  opening  by  the  lower 


THE    RING    IN    CHRONIC    INFLAMMATIONS.  897 

portions  of  the  instrument,  as  interfering  with  the  natural  func- 
tions. 

Air  Pessaries. — Many  practitioners  are  so  apprehensive  of  mis- 
chief from  hard  bodies  in  the  vagina,  that  they  have  recommended 
such  substances  as  sponge,  wool,  cotton,  etc.,  as  pessaries.  A 
more  feasible  suggestion  is  that  of  employing  gum-elastic  sacks 
filled  with  air.  Hence,  globular  pessaries  of  caoutchouc  have 
been,  by  some,  much  employed ;  while  others  have  resorted  to 
the  disk-shaped  with  a  central  perforation,  to  be  inflated  with  air. 

As  regards  these  peculiar /o?'7?2s,  the  same  advantages  and  dis- 
advantages ensue  as  have  been  pointed  out  respecting  the  disk 
and  globular  pessary.  The  objection  to  the  material,  gum-elastic, 
is,  that  decomposition  will  sooner  or  later  take  place,  necessitat- 
ing their  removal.  No  advantage  is  to  be  gained  by  the  softness 
or  elasticity  of  the  pessarj^,  which,  on  the  contrary,  may  prove 
too  yielding  to  resist  the  tendency  to  displacements. 

Ring  Pessaries. — The  ring  pessary  has  been,  of  late  more  espe- 
cially, substituted  for  all  these  varieties.  There  are  several  modi- 
fications of  this  form,  but  they  all  have  the  strong  recommendation 
of  affording  protection  to  the  cervix  uteri.  The  vagina,  on  their 
introduction,  is  made  more  or  less  tense,  so  that  the  whole  uterus 
is  supported  by  the  tent-like  expansion  of  the  superior  surface  of 
this  tube,  with  very  little  pressure  against  the  body  of  the  organ  ; 
while  the  cervix  is  entirely  free  from  pressure  of  the  instrument, 
and  even  from  resting  on  the  posterior  wall  of  the  vagina. 

This  great  recommendation  of  the  ring  pessary  in  all  its  varie- 
ties has  never  been  sufficiently  exhibited.  All  the  usual  accu- 
sations against  other  pessaries  of  producing  inflammation  of  the 
cervix,  are  not  applicable  to  the  ring.  It  produces  no  pressure 
on  the  cervix,  and  therefore  cannot  irritate  or  inflame  it.  Much 
more,  however,  is  accomplished  than  this  negative  effect.  It  re- 
moves irritation ;  it  obviates,  immediately,  all  the  bad  effects  of 
the  superincumbent  pressure  on  the  uterus,  which  produces  pro- 
lapsus, flexion  of  the  cervix,  organic  irritation,  inflammation, 
ulceration,  and  other  irritating  consequences  from  friction  against 
the  posterior  wall  of  the  vagina  and  the  feculent  accumulations 
in  the  rectum,  as  formerly  detailed.  They  thus  also  assist  the 
antiphlogistic  remedies  for  chronic  inflammation  of  the  os  uteri, 
to  which  so  much  attention  has  of  late  been  directed  in  Europe 
in  America. 


898  TREATMENT — INTERNAL    SUPPORTERS. 

As  has  formerly  been  mentioned,  the  supposed  indomitable 
character  of  these  inflammatory  disturbances  of  the  cervix  is 
often  kept  up  by  the  pressure  and  friction  of  the  os  against  the 
perineum.  This  pressure  being  obviated  by  means  of  a  ring 
pessary,  resolution  of  the  inflammation  may  occur  almost  spon- 
taneously ;  as  the  congestion  and  irritation  of  the  conjunctiva 
disappear  on  the  removal  of  a  mote  from  the  eye.  Or,  it  will 
rapidly  disappear  under  the  usual  astringent  or  detergent  washes, 
occasionally  assisted  by  solutions  of  the  nitrate  of  silver.  At 
least  such  has  been  the  author's  experience  after  the  lapse  of 
many  years,  in  which  he  has  acted  on  this  principle;  during 
which  long  period,  he  has  never  found  it  requisite  to  apply  any 
powerful  caustic  for  the  eradication  of  such  inflammations.  That 
such  caustics,  even  not  excepting  the  actual  cautery,  may  be 
sometimes  valuable,  when  judiciously  employed  in  syphilitic, 
fungous,  cauliflower,  cancerous,  and  other  specific  degenerations 
of  the  cervix,  need  not  now  be  debated.  The  magnitude  of  the 
danger  may  justify  the  heroic  character  of  the  agent;  but  let  no 
surgical  treatment  be  resorted  to  in  cases  of  phlogosed  states  of 
the  neck  of  the  womb,  which  a  respectable  surgeon  would  con- 
sider unjustifiable  in  analogous  cases,  upon  the  skin,  eye,  or 
throat  of  his  patient. 

We  have  carried  this  principle  to  a  still  greater  extent  with 
most  satisfactory  results.  In  chronic  inflammations,  where  the 
whole  cervix  has  been  indurated;  where  there  is  "ectropion"  of 
the  edges  of  the  os  from  turgescence  and  thickening  of  the  lining 
membrane  of  the  canal;  where  this  has  become  so  tender  and 
vascular  that  the  touch  of  the  finger  or  instruments,  or  pressure 
from  walking  about  the  room,  produced  sanguineous  discharges 
with  pain  and  bearing-down  sensations,  giving  anxious  suspicion 
of  some  malignancy  being  present :  in  such  cases,  the  use  of  the 
ring  has  not  merely  given  great  temporary  relief,  but  has  facili- 
tated the  subsequent  recovery  without  the  necessity  of  confining 
the  patient  to  bed,  with  all  its  enervating  results. 

Although  inflammation  of  the  uterus  is  seldom  if  ever  induced 
by  the  ring,  yet  vaginitis,  with  its  usual  consequences,  may  ensue 
from  inordinate  pressure  due  to  the  size,  or  any  irregular  portion 
of  the  ring ;  hence  leucorrhcea,  purulent  discharges,  ulcerations, 
and  adhesions,  may  by  inattention  or  carelessness  be  excited  as 
by  other  pessaries. 


FLAT    KING.  899 

A  caution  perhaps  may  be  useful  as  regards  the  thickness  of 
the  pessary.  Very  thin  ones  indent  the  vagina,  and  are  apt  to 
irritate ;  while  very  wide  ones — we  have  used  them  an  inch  in 
thickness  and  of  course  proportionally  small  in  diameter — prove 
injurious  to  the  cervix,  not  only  by  confining  the  fluids,  but  by 
acting  as  a  suction  power  facilitating  the  engorgement  of  the  cer- 
vix, and  its  consequent  enlargement.  This  bad  effect  we  have 
witnessed  so  frequently  that  its  occurrence  should  be  appre- 
hended. 

The  fiat  ring  pessary  as  a  uterine  supporter  has  similar  influ- 
ences with  the  Dewees  pessary,  but  perhaps  is  not  so  efficient. 
It  often  answers  very  well  in  procidentia  uteri,  when  there  is 
great  relaxation  of  the  vagina ;  but  it  does  not  so  well  retain  the 
vagina  within  the  vulva  as  the  concavo-convex,  or  the  plano-con- 
vex instruments. 

In  the  other  forms  of  displacement,  it  also  seems  inferior  to  the 
disk,  as  the  convexity  of  the  disk  towards  the  rectum  renders  it 
more  movable  with  the  uterus,  and  allows  the  upper  margin 
under  the  uterus  to  rise  higher  on  the  face  of  the  rectum  and 
sacrum. 

As  intimated,  the  inefficiency  of  this  form  of  the  ring  arises 
from  its  flatness.  Under  the  pressure  from  above,  it  will,  indeed 
must,  remain  parallel  to  the  plane  of  the  perineum.  Hence,  one 
part  of  the  circumference  may  be  felt  towards  the  orifice  of  the 
vagina,  while  the  opposite  segment  necessarily  presses  against  the 
rectum.  As  the  patient  walks  and  strains,  this  pressure,  if  the 
pessary  be  large,  may  become  very  inconvenient  and  sometimes 
intolerable ;  it  keeps  up,  in  such  cases,  a  tenesmus,  a  sense  of 
weight  and  pressure,  and  in  some  instances  partially  or  completely 
obstructs,  like  a  valve,  the  feculent  evacuations,  while  under  the 
straining  efforts  of  the  patient  the  closure  of  the  intestine  becomes 
more  perfect.  The  anterior  segment  of  the  ring  often  rises  against 
the  urethra,  causing  dysuria,  or  even  retention  of  the  urine,  de- 
manding the  removal  of  the  instrument. 

In  retroversion  of  the  womb,  very  trifling  advantage  is  gained, 
in  most  cases,  by  the  use  of  this  flat  ring,  as  the  fundus  is  pushed 
up  by  it  only  a  short  distance  from  the  coccyx,  while  pressure  of 
the  body  of  the  uterus  against  the  ring  but  aggravates  the  obstruc- 
tion to  the  faeces  in  the  rectum  with  its  bad  consequences. 

To  obviate  these  effects,  it  has  been  suggested  to  increase  the 


400 


TREATMENT  —  INTERNAL    SUPPORTERS, 


diameter  of  the  instrument,  that  it  might  rise  higher  on  the 
sacrum,  and  through  the  medium  of  the  vagina  acting  on  the 
posterior  lip  of  the  cervix  might  draw  the  neck  backwards 
towards  the  sacrum,  and  thus  facilitate  the  ascent  of  the  fundus 
from  the  surface  of  the  rectum  and  sacrum.  Practice  does  not 
confirm  these  expectations,  the  pessary  remains  flat  on  the 
perineum,  and  the  location  of  the  cervix  is  not  much  affected 


THE    FLAT    KING    IN    POSITION, 


through  the  medium  of  the  vagina ;  the  neck  either  does  not 
move,  or  if  somewhat  drawn  back,  flexion  is  produced,  or  in- 
creased, if  already  existing,  while  the  fundus  still  rests  in  the  hol- 
low of  the  sacrum.  At  least  this  is  our  constant  experience,  of 
which  we  have  had  a  great  deal  in  the  use  of  this  form  of  the  in- 
strument, as  after  abandoning  the  circular  disk,  it  was  chiefly 
with  the  flat  ring  that  most  of  our  observations  were  originally 
made.     These  facts  are  represented  in  the  diagram. 

The  ordinary  flat  rings  are  to  be  introduced  and  removed  in  the 
same  manner  as  the  disk  pessary.  When  in  proper  position  the 
posterior  margin  of  the  ring  should  be  behind  the  neck  of  the 
uterus. 


STEM-PESSARIES.  401 

To  introduce  a  large  sized  ring,  especially  in  cases  of  a  con- 
tracted orifice  of  the  vagina,  two  suggestions  have  been  made. 
The  first  by  the  author  consisted  in  removing  a  segment  of  the 
circumference  from  an  inch  to  an  inch  and  a  half,  so  as  to  have 
an  interrupted  or  imperfect  ring.'  One  extremity  of  this  segment 
was  first  introduced  through  the  orifice,  and  the  whole  ring  was 
made  to  revolve  as  it  was  pressed  into  the  vagina,  so  that  the 
other  extremity  of  the  segment  was  the  last  part  to  enter.  When 
the  vulvo-uterine  canal  was  relaxed,  a  very  large  ring  could  thus 
be  emjjloyed  with  very  little  pain  or  difficulty. 

The  other  suggestion  has  been  strongly  recommended  by  Dr. 
Meigs,  of  the  Jefi'erson  Medical  College.  It  consists  of  a  watch 
spring  of  delicate  steel  well  covered  with  thread,  and  afterwards 
frequently  dipped  in  a  solution  of  gutta  percha  in  chloroform, 
until  it  has  received  a  coating  of  the  requisite  thickness.  This 
ring  is  very  elastic,  and  can  therefore  be  readily  compressed  into 
an  elliptical  shape,  and  thus  easily  pushed  into  the  vagina,  where 
it  resumes  its  circular  form. 

Whatever  ingenuity  may  be  thus  manifested,  as  regards  the  in- 
troduction and  removal  of  a  large  pessary,  yet  no  beneficial  change 
is  effected  in  the  operation  of  the  ring  by  its  increased  size. 

Lately  we  removed  a  large  ring  pessary  of  fu'll  three  and  a  half 
inches  in  diameter,  from  a  lady  with  a  retroflexed  uterus,  which 
still  allowed  the  fundus  to  remain  in  the  hollow  of  the  sacrum. 

Stem- Pessaries. — The  inefficiency  of  all  the  pessaries  above 
alluded  to,  in  cases  of  retroversion,  has  been  practically  found 
so  great,  that  numerous  modifications  of  the  ball,  conical,  ring  and 
other  forms,  have  been  made  and  connected  with  stems  or  handles, 
projecting  out  of  the  orifice  of  the  vagina,  so  as  to  maintain  the 
pessary  in  situ.  By  most  operators,  these  stems  have  been  at- 
tached to  a  framework  and  bandages  outside  of  the  body.  Fail- 
ing in  various  efforts  to  rectify  the  position  of  the  uterus,  by 
means  of  the  circular  or  elliptical  ring,  we  also  endeavored  to 
increase  the  efficiency  of  the  instrument  by  the  addition  of  stems, 
but  found  that  they  were  productive  of  too  much  irritation. 

Without  going  into  details  as  to  the  varieties  of  stem-pes- 
saries, used  extensively  in  Europe  and  America,  the  following 
serious  objections  may  be  urged  against  their  employment.     The 

'  See  diagram,  p.  415. 

26- 


402       TEEATMENT  —  INTERNAL  SUPPORTERS. 

external  framework  and  bandages  are  all  productive  of  incon- 
venience, and  frequently  of  positive  mischief,  as  already  men- 
tioned, when  speaking  of  external  supporters.  They  must  be 
frequently  removed,  sometimes  even  to  allow  of  the  natural 
evacuations,  and,  of  course,  they  have  to  be  readjusted  by  the  pa- 
tient herself,  ignorant  of  the  indications  to  be  fulfilled. 

The  stem,  however  smoothly  made,  and  of  whatever  size,  proves 
a  powerful  irritant  by  the  pressure  and  frictions  against  the  very 
sensitive  tissues  at  the  orifice  of  the  vagina,  and,  to  many  patients, 
is  actually  intolerable.  Few  persons  can  bear  its  constant  use 
for  any  length  of  time ;  indeed,  the  instrument  is  very  universally 
removed  upon  retiring  to  bed.  Hence,  the  little  advantage  to  the 
displacement  gained  during  the  day,  will  be  lost  at  night. 

Perhaps  the  most  serious  objection  to  stem-pessaries  has  not  been 
sufficiently  regarded,  namely,  their  immobility.  The  pessary  in 
the  vagina  becomes  a  fixed  point  by  means  of  the  stem.  It  yields 
naught  to  the  natural  motions  of  the  uterus ;  it  affords  a  firm  re- 
sistance to  any  part  of  the  vagina,  and  of  the  neck  or  body  of  the 
uterus,  against  which  it  may  impinge  during  every  effort  of  the 
patient,  in  standing,  walking,  straining,  etc.  Pain  and  irritation 
must  necessarily  result  to  the  detriment,  if  not  serious  injury,  of 
the  tissues.  The  reason,  doubtless,  that  no  more  bad  effects  have 
resulted,  is  that  such  supporters  are  used  only  for  the  occasion. 
They  are  removed  when  the  patient  is  at  rest,  whether  by  day  or 
night. 

Finally,  stem  pessaries  are  universally,  with  one  exception, 
hereafter  to  be  mentioned,  incapable  of  sustaining  the  uterus  in 
the  direction  of  the  axis  of  the  superior  strait.  All  these  arrange- 
ments are  predicated,  it  would  seem,  on  the  simple  idea  of  keep- 
ing the  uterus,  within  and  at  a  certain  distance  from  the  orifice  of 
the  vagina,  without  any  attention  being  paid  to  the  natural  posi- 
tion of  the  OS  and  fundus. 

Should  these  reasons  be  found  valid  by  others,  as  they  are  con- 
firmed by  the  observations  of  the  author,  stems  will  be  univer- 
sally abandoned,  not  only  as  useless,  but  as  injurious. 

Notwithstanding  these  and  other  analogous  objections  to  stem- 
pessaries,  they  are  still  much  employed ;  as  patients  suppose  that 
they  can  thus  be  independent  of  their  medical  attendant. 

Simpson's  Intra-uierine  Pessaries. — Numerous  other  varieties  of 
pessaries  have  been  proposed,  which,  perhaps,  universally  fail  in 


INTRA-UTERINE.  403 

the  essential  point  of  giving  proper  direction  to  tlie  body  of  the 
uterus,  and,  therefore,  need  not  even  be  described.  To  this  ob- 
servation there  is  one  important  exception  as  regards  a  compara- 
tively new  instrument,  combining  the  external  framework,  the 
vaginal  stem  and  pessary,  with  a  stem  or  style  to  project  into  the 
cavity  of  the  neck  and  of  the  body  of  the  uterus.  Professional 
attention  has  been  turned  to  this  "intra- uterine  pessary,"  as  it  is 
termed,  by  the  talented  but  enthusiastic  Professor  in  the  Univer- 
sity of  Edinburgh,  now  Sir  James  Y.  Simpson,  with  whose  valua- 
ble suggestions  on  many  subjects  the  profession  are  familiar.  His 
course  is,  however,  to  be  followed  like  that  of  most  pioneers, 
"cum  magna  prudentia  longo  intervallo:"  especially  in  the  em- 
ployment of  this  instrument,  very  efficient  in  restoring  or  fixing 
the  uterus  in  its  normal  position,  but  fraught  with  many  dangers. 

Dr.  Simpson  having  found  that  although  the  uterus  could  be 
restored  to  its  proper  position  by  the  uterine  sound,  yet,  upon  the 
removal  of  this  instrument,  the  displacement  immediately  re- 
curred, however  often  the  operation  had  been  repeated,  conceived 
the  idea  of  retaining  a  short  sound  for  a  certain  time  in  the  cavity 
of  the  uterus  by  a  suitable  apparatus.  After  various  attempts,  he 
succeeded  to  his  own  satisfaction,  and  has  presented  us  with  three 
modifications  of  his  "  intra-uterine  pessary."  The  first  and  second 
consist  of  the  extremity  of  a  uterine  probe,  perfectly  straight, 
two  inches  and  one-third  in  length,  and  connected  with  a  flat  cir- 
cular disk  at  its  lower  extremity,  which  in  the  first  was  solid, 
smooth,  and  small ;  in  the  second  this  disk  was  larger,  of  an  ovoid 
shape,  in  the  centre  of  which  was  again  a  smaller  disk,  with  its 
upright  probe.  This  central  portion  was  ingeniously  connected 
with  the  larger  by  a  "  spring  catch,"  so  adjusted  that  the  angle 
of  the  stem  could  be  altered  in  order  to  allow  of  its  ready  intro- 
duction, and  then  readjusted  and  "  locked"  so  as  to  maintain  it  in 
its  proper  position,  and  unlocked  when  it  became  necessary  to 
remove  it.  These  two  varieties  need  not  again  be  alluded  to,  as 
Dr.  Simpson  reports  that  the  larger  as  well  as  the  smaller  could 
not  be  relied  upon  in  the  treatment  of  retroversion,  though  they 
answered  in  cases  of  anteversion,  which  can  be  easily  relieved  by 
almost  any  form  of  pessary,  certairfly  more  safe  and  manageable 
than  the  intra-uterine. 

The  third  form,  on  which  he  places  great  reliance,  has,  as  in 
the  first,  the  central  disk  or  vaginal  portion,  and  the  probe  or 


404  TREATMENT  —  INTERNAL    SUPPORTERS. 

uterine  portion.  From  the  anterior  part  of  the  disk  projects  a 
curvilinear  flat  tube.  There  is  also  a  framework,  to  be  arranged 
outside  of  the  body,  and  extends  from  the  orifice  of  the  vagina 
five  inches  upwards  to  and  over  the  symphysis  pubis,  is  half  an 
inch  in  breadth  below,  but  over  the  pubis  enlarges  to  the  width 
of  three  inches.  To  the  lower  or  perineal  portion  of  this  frame 
is  attached  another  tubular  stem,  closed  at  the  outer  extremity 
and  smaller  than  the  former,  so  that  it  can  be  readily  made  to  slide 
into  the  tube  attached  to  the  circular  disk.  The  intra-uterine 
stem,  with  its  vaginal  disk,  is  to  be  first  introduced,  and  by  them 
the  retroverted  organ  is  to  be  restored;  then  the  flat  stem  of  the 
external  frame  is  to  be  pushed  into  the  flat  tube  of  the  vaginal 
disk,  so  as  to  form,  as  it  were,  but  one  solid  stem,  two  and  a  half 
inches  long,  from  the  internal  disk  to  the  external  frame.  The 
framework  being  composed  of  a  flexible  metal,  can  be  bent  at 
pleasure,  and  is  to  pass  in  front  of  the  vulva,  and  the  spreading 
portion  to  be  moulded  over  the  mons  veneris,  so  as  to  prevent 
motion  and  give  a  fixed  character  to  the  framework,  to  the 
vaginal  stem,  and  of  course  to  the  intra-uterine  probe  or  pessary. 
This  arrangement  is  generally  suf&cient;  but  tapes  and  bandages 
around  the  loins,  and  more  frequently  a  napkin  over  the  vulva, 
with  the  usual  arrangements  for  its  support,  are  sometimes  de- 
manded. 

This  apparatus  is  to  be  worn  from  one  week  to  some  six  or 
eight  months  at  all  times,  even  during  the  flow  of  the  menses.  It  is 
said  that  after  some  alterations,  to  adapt  it  to  the  sensations  of  the 
patient,  it  can  be  often  worn  without  inconvenience,  supporting 
the  organ  in  situ,  allowing  the  patient  to  take  exercise,  and  ab- 
solving her  from  the  sufferings  of  uterine  irritation ;  and  that,  after 
being  worn  for  a  few  months,  the  uterus  will,  of  itself,  remain  in 
situ,  and  the  patient  continue  well. 

Such  are  the  favorable  reports  of  the  operation  of  this  instru- 
ment by  its  inventor,  who,  however,  frankly  acknowledges  that 
there  are  cases  to  which  it  is  inapplicable,  and  that  symptoms  are 
sometimes  produced  which  necessitate  its  abandonment. 

There  are,  we  think,  so  many  serious  objections — theoretical 
and  practical — to  be  urged  against  this  apparatus,  that  it  would 
seem  to  be  impossible  that  it  should  come  into  general  use.  Its  em- 
ployment will  probably  be  confined  to  special  cases,  or  restricted 
to  those  few  individuals  who  are  so  exact  in  their  diagnosis  as  to 


OBJECTIONS  TO  THE  INTRA- UTERINE.       405 

estimate  aright  the  peculiar  cases  to  which  it  is  adapted,  and  so 
cautious  in  their  practice,  as  to  watch  their  patient  day  after  day, 
not  to  say  hour  after  hour. 

One  important  objection  to  the  instrument,  as  proposed,  is  the 
oxidizable  character  of  the  metals  employed — German  silver,  or 
a  mixture  of  silver  and  nickel.  Dr.  Simpson  has  also  employed 
lead,  and  copper,  for  the  vaginal  disk.  These  metals,  from  the 
moisture,  atmospheric  air  and  heat  in  the  vagina,  will  oxidize 
with  more  or  less  rapidity,  and  thus  be  corroded ;  and  their  oxides, 
combining  with  the  acid  secretions  of  the  tissues,  may  become 
more  or  less  irritating.  The  effect,  if  any,  in  preserving  the 
metals  in  their  natural  state  which  may  arise  from  any  galvanic 
influence  due  to  the  combination  of  different  metals,  must  be  de- 
cided by  the  chemist  and  by  observation. 

The  second  objection  is  from  the  frequent  necessity  of  employ- 
ing napkins,  tapes,  and  bandages,  with  all  their  uncleanliness 
and  frictions,  especially  in  warm  weather,  with  the  absolute  neces- 
sity of  repeatedly  changing  them,  as  have  been  specified  when 
speaking  of  external  supporters. 

The  external  framework  itself  is  a  great  objection,  rising  up 
in  front  of  the  sensitive  tissues  of  the  nymphs,  clitoris,  and  labia, 
and  liable  to  produce  more  or  less  friction  and  pressure;  its  mo- 
bility is,  with  all  care,  often  so  great  that  it  cannot  be  worn  with- 
out additional  applications,  as  tapes  or  bandages. 

The  vaginal  stem  must  excite  more  or  less  irritation  against 
the  urethra,  nymphae,  and  other  sensitive  tissues,  which  few 
patients  will  bear. 

The  fixed  character  which  all  vaginal  stems  give  to  pessaries 
has  already  been  pointed  out  as  a  most  serious  objection.  They 
never  yield  to  pressure  from  above.  The  internal  irritable  tissues 
are  pressed  against  them  forcibly  at  all  times  when  the  patient  is 
erect,  and  often  violently  in  coughing,  vomiting,  sneezing,  etc. 
In  the  case  of  an  intra-uterine  pessary,  this  objection  is  stronger 
than  in  all  others,  as  the  points  of  internal  resistance  are,  first, 
the  mouth  of  the  uterus ;  secondly,  its  internal  surface ;  and 
thirdly,  in  some  cases,  the  upper  or  transverse  side  of  the 
triangular  cavity  of  the  uterus,  directly  against  the  point  of  the 
intra-uterine  stem. 

The  chief  pressure  is  received  against  the  orifice  of  the  uterus, 
and  the  lower  extremity  of  the  cervix,  which  rests  on  the  vaginal 


406  TEEATMENT — INTERNAL    SUPPORTERS. 

disk — a  fixed  point.  In  all  tlie  impulses  from  above,  the  impres- 
sion is  made  on  these  delicate  and  irritable  tissues,  so  that  some- 
times the  orifice  is  even  dilated  by  the  pressure  against  the  disk. 
It  has  already  been  pointed  out  in  detail,  that  the  results  of  such 
pressure  in  neglected  cases  of  prolapsus  uteri,  against  even  the 
soft  parietes  of  the  vagina,  are  flexion,  soreness,  nervous  disturb- 
ance, pain,  inflammation,  continuing  for  years,  with  the  granular, 
and  sometimes,  it  is  said,  even  with  the  ulcerated  condition  of  the 
mucous  membrane.  It  was  also  shown  that  such  inflammations 
of  the  OS  were  aggravated  by  the  ball,  the  concave  disk,  the 
double  and  plano-convex  pessaries,  even  though  they  were  mova- 
ble in  the  vagina.  The  theoretical  conclusion,  therefore,  is  clear, 
that  more  irritation  would  ensue  when  the  disk  is  held  immova- 
ble, as  in  the  intra-uterine  pessary,  against  the  orifice  by  means 
of  the  stem. 

We  experimented  several  times  with  the  intra-uterine  stem  and 
disk,  generally  in  women  whose  catamenia  had  ceased,  and  where 
no  marked  sensitiveness  existed  in  the  uterus.  In  each,  after  a 
few  days,  leucorrhoeal  and  bloody  discharges  ensued,  with  ..con- 
siderable pain  and  irritation,  sufiicient  to  indicate  the  propriety 
of  discontinuing  the  instrument. 

The  intra-uterine  probe  is  said  to  be  worn  with  impunity. 
This  testimony  should  not  be  received  without  great  caution,  if 
we  reflect  upon  the  sensibility  of  the  internal  tissues  of  the  uterus, 
so  great  indeed  that  a  uterine  sound  can  seldom  be  introduced, 
especially  through  the  internal  os  uteri,  without  causing  severe 
pain,  sometimes  agonizing,  if  we  may  judge  from  the  exclama- 
tions of  the  patient,  and  from  the  intolerance  of  the  uterine  cavity 
to  fluids,  simple  as  well  as  stimulating.  The  vascularity  and 
delicacy  of  the  lining  membrane  are  so  great,  that  probing  the 
uterus  is  generally  followed  by  the  eft'usion  of  blood ;  and  the 
slightest  mental,  as  well  as  physical  excitement,  will  often  pro- 
duce leucorrhoeal  and  menorrhagic  discharges. 

In  the  case  of  the  intra-uterine  pessary,  the  internal  stem  is 
not  merely  always  in  contact  with  these  sensitive  vascular  tissues, . 
but  presses  upon  them  more  or  less  firmly  during  every  motion 
of  the  body,  as  this  stem  constitutes  the  means  by  which  the 
organ  is  kept  in  position.  It  is  not,  therefore,  to  be  wondered  at 
that  in  irritable  and  congestive,  as  well  as  inflammatory,  states  of 
the  uterus  this  instrument,  as  is  acknowledged,  cannot  be  borne, 


DANGERS    OF    THE    INTRA  -  UTE  RINE.  407 

or  that  it  has  sometimes  to  be  removed  because  leucorrhoeal  or 
hemorrhagic  discharges  are  excited  or  increased.  The  greater 
wonder  is  that  such  irritations  and  discharges  are  not  the  con- 
stant and  unavoidable  result  in  all  cases.  That  such  is  not  the 
uniform  effect  can  only  be  explained  by  that  law  of  vital  tissues 
by  which,  under  constant  pressure,  if  not  too  severe,  parts  be- 
come gradually  more  insensible  to  irritations. 

The  most  serious  pressure  is,  however,  to  be  apprehended  from 
the  point  of  the  instrument  against  the  internal  and  superior  sur- 
face of  the  cavity.  Dr.  Simpson  has  attempted  to  obviate  this 
danger  by  making  the  instrument  shorter  than  the  long  axis  of 
the  cavity.  The  internal  stem  measures  two  inches  and  one- 
third,  while  two  inches  and  a  half  is  the  usual  length  of  the 
uterine  axis  internally.  The  difference  is  merely  two  lines,  or 
one-sixth  of  an  inch !  What  possible  security  can  be  given  that, 
in  the  various  motions,  this  small  space  of  one-sixth  of  an  inch 
will  not  be  obliterated,  and  that  the  fundus  will  not  impinge 
against  the  point  of  the  probe?  If  the  uterus  were  perfectly 
firm — as  if  made  of  metal,  of  bone,  or  even  of  cartilage — such  an 
accident  could  not  perhaps  occur ;  but  the  tissue  of  the  uterus, 
although  firm,  is  flexible,  and  bending  of  the  organ  is  a  fact  of 
daily  observation.  With  an  intra-uterine  supporter  there  can  be, 
it  is  true,  no  marked  lateral,  anterior,  or  posterior  flexion,  the 
metallic  rod  within  resists  such  changes ;  but  the  whole  superin- 
cumbent pressure  must  free  the  fundus  downwards,  and  as  the 
opposite  extremity  of  the  organ  is  fixed  by  the  vaginal  disk,  the 
yielding  of  the  uterus  will,  therefore,  be  from  above  downwards, 
in  the  direction  of  its  length  :  all  such  yielding  will  endanger  the 
forcible  impinging  of  the  uterus  against  the  point  of  the  internal 
stem.  This  danger  is  aggravated  by  the  gradual  dilatation  of  the 
OS,  and  the  eversion  of  its  lips,  so  that  the  stile  penetrates  still 
deeper  into  the  organ.  Either  of  these  circumstances — and,  of 
course,  still  more  when  both  are  in  unison — can  readily  shorten 
the  perpendicular  diameter  of  the  uterus  one-sixth  of  an  inch, 
when  mischief  of  a  serious  character  would  inevitably  ensue — 
inflammation,  ulceration,  even,  it  may  be,  perforation  of  the 
uterus,  and  peritonitis  with  its  dire  consequences.  Such  results 
are  said  to  have  occurred,  and  certainly  are  to  be  apprehended, 
especially  as  few  are  expert  enough  to  measure  and  arrange  the 
safe  proportions  which  ought  to  exist  between  the  length  of  the 


408  TREATMENT  —  INTERNAL    SUPPORTERS. 

stile  and  that  of  any  individual  uterus.  Dr.  Simpson  speaks  of 
using  one  some  three  and  a  half  inches  long  in  a  hypertrophied 
organ  with  impunity;  but  one  of  our  western  physicians,  less 
skilled  in  diagnosis,  inserted  an  intra- uterine  pessary,  with  a  stem 
five  inches  in  length,  into  a  uterus  whose  length  was  found  to  be 
but  three  inches  when  measured  by  the  uterine  sound.  The  in- 
strument is  in  our  possession. 

This  particular  danger  can  easily  be  lessened  in  a  great  degree 
by  diminishing  the  length  of  the  stem,  so  as  to  allow  half  an  inch 
or  six  lines  between  the  internal  surface  of  the  fundus  and  the 
point  of  the  stem.  Nevertheless,  the  strong  objections  that  the 
uterus  is  firmly  fixed  by  an  immovable  pessary,  and  the  irritation 
arising  from  the  intra-uterine  stem,  etc.,  must  be  regarded  as  of 
serious  import.  Minor  objections  may  be  alluded  to,  such  as  the 
occupation  of  the  vulva  and  vagina  so  as  to  prevent  the  natural 
uses  of  this  canal ;  and  the  irritations  and  discharges  which  the 
vaginal  stem  would  usually  produce. 

That  the  instrument  is  to  be  worn  but  a  few  months  at  farthest, 
and  that  then  it  may  be  removed  without  a  return  of  the  dis- 
placement, is  one  of  those  assertions  of  an  experienced  physician 
which  to  most  other  persons  is  altogether  incomprehensible.  That 
a  recent  case  of  retroversion  may  disappear  by  rest  and  quietness, 
after  reposition — that  a  displacement,  occurring  soon  after  deli- 
very, may,  if  restored,  be  permanently  relieved  by  the  contrac- 
tion of  the  ligaments  which  then  quickly  occurs — can  be  under- 
stood. But  that  a  chronic  retroversion,  where  the  ligaments  and 
other  supports  have  been  for  a  long  time  inef&cient,  will  usually 
disappear  if  the  organ  be  retained  in  position  for  a  few  weeks  or 
months,  cannot  be  so  readily  comprehended.  Dr.  Simpson  makes 
no  explanation,  but  simply  enunciates  the  fact,  as  he  regards  it. 
The  author's  experience  is  altogether  at  variance  with  this  idea. 
The  displacement  is  apt  to  return,  even  if  the  uterus  for  one  or 
more  years  may  have  been  steadily,  night  and  day,  kept  in  situ ; 
and  although,  in  some  cases,  a  support  may  be  removed,  as  the 
writer  has  done,  in  three  and  six  months,  with  impunity,  yet. 
such  are  always  to  be  regarded  as  exceptionable  cases,  and  not 
as  the  rule. 

The  intra-uterine  pessary  with  its  external  appendages  must, 
however,  be  regarded  as  the  most  efficient  instrument  for  main- 
taining a  uterus,  after  its  restoration  to  its  natural  position,  that 


MODIFICATION    OF    THE    INTRA- UTERINE.  409 

lias  yet  been  presented  to  the  profession.  It  is  impossible, 
with  the  external  framework  and  intra-uterine  stile  duly  con- 
nected and  located,  that  the  displacement  should  return.  The 
pessary  is  immovable,  and  so  is  therefore  the  uterus  itself.  Must 
it  not,  however,  for  these  very  reasons,  be  regarded  as  peculiarly 
dangerous ;  and,  although  perhaps  to  be  occasionally  employed  in 
special  cases  by  the  careful  and  instructed  surgeon,  it  ought  not 
to  come  into  general  use.  Certainly  there  are  numerous  cases  to 
which  it  is,  in  the  eyes  of  all,  inapplicable,  as  where  there  are 
great  irritability  and  tenderness  of  the  vulva,  the  orifice  of  the 
vao-ina  and  the  uterus ;  where  there  is  congestion  of  the  uterus,  or 
inflammation  of  the  os  and  cervix  uteri ;  under  all  circumstances, 
in  virgins ;  and  where  the  uterus  is  from  some  cause  fixed,  as  by 
tumors,  adhesions,  etc.,  and  cannot  be  at  once  elevated  to  its 
normal  position. 

The  answer,  of  course,  given  by  the  friends  of  this  instrument 
is  that  experience  is  in  its  favor.  If  so,  the  question  is  decided ; 
our  best  reasoning  and  all  our  fears  must  yield  to  stubborn  facts. 
The  question  is,  however,  still  to  be  determined,  for  it  would  seem 
that  even  with  the  originator,  experience  has  been  limited  to  non- 
irritable,  non-congested,  and  movable  states  of  the  uterus ;  and 
yet  it  is  well  known  that  in  a  large  proportion  of  retroverted  uteri 
there  is  much  sensibility  and  often  much  engorgement.  The  ex- 
perience of  physicians  even  in  the  British  isles,  and  on  the  conti- 
nent of  Europe,  has  not  yet  presented  any  decided  testimony  in 
its  favor ;  and  there  certainly  has  been  much  opposition  to  its  use, 
especially  if  we  may  judge  from  the  debates  in  the  French  Impe- 
rial Academy  of  Medicine,  and  the  report  of  M.  le  Dr.  Depaul. 
In  America  we  have  seen  no  favorable  reports  of  any  importance. 
The  writer  has  heard  of  its  employment  in  some  cases,  but  with 
no  permanent  advantage.  He  has  had  patients  who  had  worn 
it,  but  with  great  suffering,  giving  rise  to  constant  irritation, 
pain,  and  hemorrhage,  necessitating  its  abandonment.  Even  in 
the  cases  in  which  he  ventured  to  use  an  intra-uterine  pessary — 
with  the  probe  half  an  inch  shorter  than  the  long  diameter  of  the 
uterus,  and  the  vaginal  disk  attached  to  an  elliptical  ring  pessary 
as  a  substitute  for  the  external  framework  and  stem,  so  as  to 
allow  mobility  to  the  uterus,  and  have  the  whole  instrument 
within  the  pelvis — the  occurrence  of  irritation  and  hemorrhage 
from  the  os  and  labia  of  the  uterus,  induced  him  to  abandon  the 


410  TREATMEN'T — INTERlSrAL    SUPPORTERS. 

experiment,  alfhougli  made  in  women  after  "  a  change  of  life" 
had  occurred.^ 

Simpsonh  Intra-  Uterine  Pessary  modified. — We  venture  to  present 
a  drawing^  of  the  modification,  just  alluded  to,  of  Dr.  Simpson's 
intra-uterine  pessary.  As  will  be  observed,  a  vaginal  elliptical 
ring  was  substituted  for  the  external  framework,  and  the  intra- 
uterine stem  made  shorter.  The  experiment,  as  regarded  the 
maintenance  of  the  uterus  in  position,  was  a  perfect  success,  and 
at  the  same  time  more  mobility  was  allowed  to  the  organ  under 
the  muscular  efforts  of  the  patient,  and  all  the  irritation  and 
annoyance  due  to  an  external  apparatus  were  done  away  with. 

The  intra-uterine  stem  was  made  but  two  inches  in  length  for 
a  uterus  measuring  two  and  a  half  inches  internally.  The  vagi- 
nal disk  had  attached  to  a  point  in  its  circumference  a  short  stile 
four  lines  in  length,  with  a  small  foramen  at  its  outer  extremity. 
The  disk  with  its  stile  should  make,  with  the  intra-uterine  stem, 
an  acute  angle,  about  40°  to  50°,  corresponding  somewhat  to  that 
made  by  the  axis  of  the  uterus  with  that  of  the  vagina.  An 
elliptical  ring  was  then  made,  slightly  curved  in  its  length,  and 
two  inches  and  a  half  long  by  two  inches  broad  (but  of  course 
the  size  must  vary  with  the  size  of  the  vagina),  and  with  a  per- 
foration in  a  longitudinal  direction,  through  the  bar  at  one  ex- 
tremity to  receive  the  stile. 

Before  introduction^  a  strong  thread  or  a  fine  flexible  wire  is  to 
be  passed  through  the  eye  in  the  vaginal  stile.  The  pessary  is 
then  passed  into  the  vagina,  the  stem  carefully  introduced  into 
the  cavity  of  the  uterus,  and  the  organ  may  be  partially  elevated. 
The  string,  hanging  out  of  the  vagina,  should  now  be  carried 
through  the  opening  in  the  extremity  of  the  ring.  The  ring  is 
then  introduced  into  the  vagina,  with  its  convexity  toward  the 
bladder,  and  the  string  being  made  somewhat  tense,  acts  as  a  di- 

'  Although  more  than  eight  years  have  elapsed  since  the  above  observations 
were  written,  we  read  of  but  little  favorable  testimony  respecting  this  intra-uterine 
pessary.  It  seems  to  be  very  universally  abandoned  on  the  Continent  of  ilurope, 
and  few  writers  of  repute  iu  the  British  Isles  or  in  America  have  ventured  to 
commend  it.  All  acknowledge  that  it  is  a  dangerous  instrument;  many  speak 
of  fatal  results  from  its  employment,  although  in  some  very  peculiar  and  unman- 
ageable cases,  some  might  countenance  a  cautious  experiment  with  this  pessary, 
carefully  watching  the  progress  of  the  symptoms. 

2  See  diagram,  p.  415. 


MODIFICATION    OF    THE    INTRA- UTERINE. 


411 


rector,  hj  wliicTi  the  ring  can  be  pushed  so  as  to  cause  the  vaginal 
stile  to  enter  the  foramen  in  the  ring.  The  string  is  now  to  be 
withdrawn ;  the  pressure  of  the  vagina,  etc.,  will  keep  the  ring 
firmly  fixed  on  the  stile,  so  that  the  direction  of  the  intra-uterine 


MODIFIED    INTRA-UTERINE    PESSARY IN    POSITION. 


probe  represents  that  of  the  axis  of  the  uterus,  and  the  pessary 
that  of  the  vagina.  If  the  uterus  be  not  perfectly  restored,  a  little 
pressure  on  the  ring  will  accomplish  this  purpose ;  and  the  ante- 
rior wall  of  the  vagina  under  the  influence  of  the  superincumbent 
weight  of  the  viscera,  increased  by  muscular  effort,  will  constantly 
depress  the  pubic  extremity  of  the  ring  towards  the  perineum, 
and  thus  compel  the  uterus  under  the  command  of  the  stem  to 
follow  its  motions.  All  these  tissues  being  pliable  and  elastic  will 
allow  a  certain  degree  of  yielding  of  the  uterus  to  the  distension 
of  the  bladder,  bowels,  etc.,  and  thus  the  instrument  does  not 
materially  interfere  with  the  mobility  of  the  womb. 

The  removal  of  this  instrument  is  very  readily  accomplished 
by  drawing  the  elliptical  ring  towards  the  orifice  of  the  vagina, 
which  detaches  it  from  the  stile,  after  which  the  vaginal  disk,  with 


412  TEEATMENT — INTERNAL    SUPPORTERS. 

the  intra-uterine  stem,  can  readily  be  removed.  If  by  any  arrange- 
ment of  tliis  kind  too  much  lateral  motion  should  be  allowed  to 
the  uterus  from  the  cylindrical  form  of  the  stile  in  the  vaginal 
disk,  this  can  readily  be  prevented  by  making  it  and  its  sheath  in 
the  extremity  of  the  ring  flat,  so  as  to  prevent  rotation. 

Whatever  modifications,  however,  may  be  suggested,  by  which 
the  evils  are  moderated,  yet  the  intra-uterine  pessary  ought  to  be 
regarded  with  great  suspicion,  and  be  very  cautiously  employed, 
even  in  the  very  limited  number  of  cases  to  which  it  is  at  all 
applicable. 


LEVER    PESSARIES,    ETC.  413 


CHAPTER    VI. 

TREATMENT    OF    D  I  S  P  L  A  C  E  M  E  N  T  S  — Contimjed.     LEVER 
PESSARIES. 

In  his  anxiety  to  fulfil  tlie  important  indication  of  keeping  the 
uterus  in  situ,  especially  when  retroversion  existed,  the  author 
has  made  innumerable  trials  through  a  long  series  of  years,  with 
almost  every  form  of  pessary,  but  finding  himself  disappointed, 
instituted  a  series  of  experiments,  which  eventually  resulted  in  a 
modification  of  the  ring  pessary,  to  which,  from  its  modus  ope- 
randi, he  has  afl&xed  the  name  of  the  "Lever  Pessary."  The  im- 
portant modification  consists  in  making  a  ring  oblong,  instead  of 
circular,  and  curved  so  as  to  correspond  to  the  curvatures  of  the 
vagina  and  rectum.  Great  advantages  result  from  this  form ; 
the  convexity  of  the  curve  being  in  contact  with  the  posterior 
wall  of  the  vagina,  corresponds,  with  more  or  less  accuracy,  to 
the  curve  of  the  rectum,  perineum,  and  sacrum.  Hence,  when 
properly  arranged,  there  is  no  pressure  against  the  rectum ;  and 
the  higher  the  instrument  rises,  the  superior  extremity,  instead  of 
impinging  against  the  rectum,  passes  upwards  and  behind  the 
uterus — 'between  this  organ  and  the  intestine — giving,  as  will  be 
presently  seen,  a  proper  position  to  the  womb,  and  yet  allowing 
its  natural  pendulum-like  motion  to  remain  unrestrained. 

The  oblong  form  and  the  curvature  are  the  two  essential  pecu- 
liarities of  the  lever  pessary ;  they  may  be  increased  or  dimi- 
nished indefinitely  according  to  the  views  of  the  practitioner,  or 
the  peculiarities  of  the  case.  In  practice,  the  author  often  modi- 
fies them  in  various  ways ;  he  would,  however,  present  chiefly 
two  varieties  for  the  consideration  and  trial  of  his  professional 
brethren,  namely,  the  oj^en  and  closed  "  Lever  Pessaries." 


414  TREATMENT — LEVER    PESSARIES. 

VARIETIES. 

Open  Lever.' — This  is  a  single-curved  parallelogram,  with 
one  of  its  sides  deficient.  It  varies  in  length  from  two  to  two 
and  three-quarter  inches,  and  in  breadth  from  one  to  two  and  a 
half  inches,  according  to  the  size  of  the  vagina;  the  sides  should 
be  from  three  to  four  lines  in  thickness.  The  curvature  is  not 
that  of  a  segment  of  a  circle,  but  is  rather  represented  by  the 
longitudinal  section  of  an  egg,  the  curve  being  greater  towards 
the  closed  extremity  than  the  opposite.  The  degree  of  curvature 
must  always  be  accommodated  to  the  emergencies  of  the  case, 
being  very  moderate  in  the  commencement  of  the  treatment  with 
a  rigid  and  short  vagina,  and  augmenting  as  the  vagina  is  relaxed 
and  elongated. 

"When  viewed  anteriorly,  its  general  aspect  is  somewhat  like  a 
magnet,  a  horseshoe,  or  the  letter  U.  It  may  be  distinguished 
by  the  name  of  the  "  open  lever^  The  two  long  and  curved  sides 
may  be  termed  the  horns,  and  their  terminations  the  points  or  the 
^^ extremities^^  of  the  horns;  the  remaining  short  or  transverse 
side  connecting  the  two  horns,  and  always  to  be  placed  under 
and  behind  the  uterus,  may  be  called  the  bar  or  upper  portion  of 
the  lever.  The  two  horns  may  be  distinguished  by  the  words 
right  and  left,  as  when  the  instrument  is  properly  adjusted,  one 
bar  always  corresponds  to  the  right,  and  the  other  to  the  left  si'de 
of  the  pelvis. 

Modus  Operandi. — To  illustrate  the  operation  of  the  lever,  we 
shall  suppose  an  irritable  retroveried  uterus,  with  a  vagina  long 
and  relaxed,  so  as  to  afford  little  resistance,  and  where  an  open 
single-curved  pessary  has  been  carefully  introduced,  according  to 
the  directions  hereafter  to  be  given.  The  bar  of  the  instrument 
will  now  be  found  behind  the  cervix  uteri,  and  the  extremities 
of  the  horns  underneath  the  cystic  portion  of  the  vagina. 

The  first  object  is  to  press  the  bar  of  the  instrument  as  high  as 
possible  between  the  posterior  surface  of  the  displaced  uterus  and 
the  rectum.  If  the  upper  portion  of  the  vagina  readily  yields, 
this  can  easily  be  accomplished,  by  placing  the  index  finger  on 
the  extremity  of  one  (say  the  left)  horn,  and  pushing  the  whole 

'  See  diagram,  p.  415. 


LEVER    PESSARIES,    ETC. 


415 


OPEN  LEVER 


VARIETIES   OF  OPEN  LEVERS 


SIDE  VIEW  OF  CLOSED  LEVER. 


416 


TREATMENT  —  LEVER    PESSARIES. 


instrument  directly  upwards  towards  fhe  sacrum,  in  tlie  cul-de- 
sac  or  pocket  of  the  vagina.  Great  caution  is,  however,  required, 
especially  when  the  organs  and  tissues  of  the  pelvis  are  morbidly 
sensitive,  so  that  the  bar  should  not  impinge  against  the  uterus 
anteriorly,  or  against  the  rectum  or  sacral  nerves  posteriorly ;  in 
either  case  severe  pain  may  be  excited.  Let  pressure  be  made 
slowly  and  steadily,  so  that  the  bar  shall  elongate  the  vagina  and 
follow  the  course  of  the  rectum  without  striking  against  this 
intestine ;  in  this  way  little  or  no  pain  will  be  excited. 

As  the  vagina  yields  and  the  bar  ascends,  the  finger  should 
depress  the  extremity  of  the  horn  gradually  from  the  bladder 


OPEN     LEVE  R 1  N     POSITION. 


towards  the  rectum,  by  which  the  bar  will  ascend  posteriorly,  ele- 
vating the  fundus  of  the  uterus,  while  the  os  uteri,  by  means  of 
its  attachment  to  the  vagina,  is  drawn  more  and  more  backwards. 
In  a  short  time  it  will  be  found  that  the  os  will  point  towards 
the  lower  part  of  the  sacrum,  and  the  fundus  towards  the  inferior 
part  of  the  linea  alba  in  front  and  above  the  pubis.  The  anterior 
surface  of  the  uterus  can  now  be  readily  felt  behind  the  bladder. 


MODUS    OPERANDI.  417 

and  supported  by  the  concavity  of  the  horns  of  the  pessary.  The 
uterus  is  therefore  replaced,  and  at  an  acute  angle  with  the  va- 
gina. (It  is  desirable,  as  represented  in  the  diagram,'  that  the  fun- 
dus be  thrown  forward  as  far  as  practicable,  to  insure  the  descent 
of  the  intestines  behind  the  uterus,  and  also  to  relax  the  ligaments 
as  much  as  possible  so  as  to  favor  their  subsequent  contraction. ; 

The  bar  of  the  instrument  in  its  location  behind  the  uterus,  can 
be  with  difficulty  reached  by  the  finger ;  while  the  extremities  of 
the  horns  can  be  readily  recognized,  one  on  the  right,  the  other  on 
the  left  side  of  the  uterus,  not  pressing  on  the  walls  of  the  vagina  at 
any  spot,  but  rather  receding  when  a  bearing-down  effort  is  made. 

The  pessary  performs  the  part  of  an  elevator.  It  operates  as  a 
lever  in  elevating  the  fundus  from  its  mal-position  against  the 
sacrum  to  its  normal  position  behind  the  bladder;  that  portion  of 
the  pessary  which  is  posterior  to  the  neck  of  the  organ  being 
the  "  short  arm,"  while  all  anterior  to  the  neck  is  the  "  long  arm," 
and  the  "  fulcrum,"  or  support,  is  the  posterior  surface  of  the 
vagina.  As  the  long  arm  or  horn  is  depressed  by  the  finger  of 
the  practitioner,  the  short  arm  rises  and  carries  with  it  the  body 
and  fundus  of  the  uterus. 

This  elevation  being  accomplished,  the  pessary  maintains  the 
organ  in  this  position.  It  acts  as  a  supporter^  for  the  intestines 
now  fall  once  more  on  the  posterior  surface  of  the  uterus,  and 
press  this  organ  against  the  long  arm  of  the  lever,  that  is,  against 
the  horns  of  the  pessary ;  so  that  when  the  woman  strains,  the 
horns  are  depressed  towards  the  rectum,  and  the  bar  of  course 
rises  behind  the  uterus.  (The  condition  of  the  patient  is  entirely 
changed ;  for,  standing  and  walking,  which  were  before  painful 
and  distressing  from  the  pressure  of  the  intestines  on  the  anterior 
surface  of  the  uterus,  increasing  the  displacement,  is  now  useful  as 
this  pressure  of  the  intestines  is  transferred  to  the  posterior  por- 
tion of  the  organ,  impelling  the  fundus  forward  towards  the 
pubis.  ^  The  woman  immediately  realizes  the  change ;  she  feels 
relieved  of  the  pressure,  the  weight,  the  dragging,  the  pain,  the 
soreness,  the  spinal  and  cerebral  distress,  and  walks  forth,  con- 
sidering the  transformation  as  wonderful,  and  hardly  believing  in 
its  reality.  Such  is  the  most  favorable  account  of  the  influence 
of  a  pessary  in  cases  of  relaxed  vagina. 

'  See  diagram,  p.  416. 

27 


418  TREATMENT  —  LEVER    PESSARIES. 

/  In  a  large  majority  of  retroverted  uteri,  the  same  bright  antici- 
pations may  be  indulged,  excepting  that  time,  even  a  long  time, 
may  be  demanded  for  the  fulfilment  of  the  important  indications 
of  replacing  the  uterus,  and  maintaining  it  in  its  proper  position. 
Many  difficulties  will  be  met  with,  such  as  shortness  and  rigidity 
of  the  vagina,  immobility  of  the  uterus,  and  its  strong  tendency 
to  retroversion,  its  large  size,  the  presence  of  tumors,  of  adhe- 
sions, etc.  In  many  of  such  cases,  patience  must  be  exercised 
by  the  physician  and  his  interesting  sufferer;  but  by  employing 
at  first  small  instruments  with  moderate  curvature,  slowly  and 
carefully  working  them  up,  day  after  day,  between  the  rectum 
and  the  uterus,  then  gradually  augmenting  their  power  by  in- 
creasing their  size,  and  especially  their  curvature  (for  the  power 
mainly  depends  on  the  degree  of  curvature),  the  displaced  fun- 
dus gradually  yields,  and  in  a  few  weeks  or  months,  the  patient 
finds  herself  relieved.  The  relief  is  generally  in  proportion  to 
the  ascent  of  the  fundus. 

In  all  these  efforts,  great  caution  is  required.  "  Festina  lent^" 
must  be  the  motto  of  the  practitioner,  and  he  should  be  guided 
very  much  by  the  sensations  of  his  patient,  remembering  the  ob- 
ject in  view  is  to  diminish,  not  to  increase,  irritation.  He  should 
encourage  the  patient  to  move  about  as  much  as  her  strength 
and  pains  will  permit.  If  there  be  an  increase  of  pain,  the  pes- 
sary presses  in  some  wrong  direction,  which  should  be  rectified 
by  a  change  of  instrument,  or  an  alteration  in  its  position.  Fre- 
quent examinations  are  necessary  to  ascertain  whether  improper 
pressure  is  made  against  the  uterus  or  sacral  nerves,  increasing 
the  pain,  or  against  the  rectum,  rendering  the  transit  of  feculent 
matters  difficult,  or  whether  the  points  of  the  horns  impinge  forci- 
bly against  the  bladder  or  the  bones  of  the  pelvis — all  of  which 
would  be  dangerous,  as  inflammation  and  ulceration  might  ensue. 
The  pessary  must  not,  therefore,  be  permittted  to  excite  organic 
irritations,  or  inflammations  from  its  size  or  too  great  pressure.  It 
should  never  be  allowed  to,  twist  and  occupy  a  transverse  direc- 
tion, as  then  it  gives  pain,  and  affords  no  support  to  the  uterus. 
The  pessary  should  always  be  borne  without  pain  or  inflamma- 
tion. The  patient  should  feel  relieved  without  any  consciousness 
of  the  presence  of  the  agent,  by  which  this  great  blessing  has  been 
bestowed. 

This  open  lever  is  equally  advantageous  in  prolapsus ;  it  keeps 


CLOSED    LEVER.  419 

the  organ  elevated,  removes  all  pressure  from  the  os  and  cervix, 
and  prevents  any  tendency  to  flexion  by  transferring  the  super- 
incumbent pressure  from  the  extremity  of  the  cervix  to  the  iufe- 
rior  portion  of  the  body  of  the  uterus,  and  to  the  tent-like  expan- 
sion of  the  anterior  wall  of  the  vagina  as  it  is  extended  over  the 
pessary. 

In  miteversion  it  operates  as  favorably ;  for,  the  horns  of  the  in- 
strument resting  on  the  perineal  portion  of  the  vagina,  prevent  the 
descent  of  the  fundus  uteri  against  the  pubis,  while,  in  proportion 
as  the  upper  extremity  of  the  vagina  yields  to  the  pressure  of 
the  bar,  the  uterus  and  pessary,  as  one  body,  descend  on  the  plane 
of  the  vagina  and  perineum  towards  the  sacrum. 

In  procidentia  we  have  also  completely  succeeded  with  the  open 
lever ;  but,  as  intimated,  the  relaxed  vagina  will  often  descend 
even  externally  in  folds  between  the  horns  of  the  pessary ;  the 
four-sided  lever,  or  even  Dewees'  pessary  may,  in  such  cases,  be 
preferable. 

The  incidental  advantages  of  the  open  lever  are  of  considerable 
importance.  Pessaries  thus  formed,  even  when  of  large  size,  can 
be  much  more  readily  and  less  painfully  introduced  and  removed 
than  the  four-sided  instrument,  as  will  be  presently  detailed. 
They  allow  of  the  free  exit  of  the  menstrual,  leucorrhoeal,  and 
other  vaginal  discharges,  and  of  the  ready  access  to  the  os  and 
cervix  uteri  of  all  cleansing  and  medicated  lotions.  Moreover, 
in  coitu  nulla  obstructio  est,  a  circumstance  occasionally  of  no 
minor  importance.  Thus,  by  its  use,  the  comfort  and  the  health 
of  the  patient  can  be  promoted,  and  the  instrument  can  often  be 
worn  for  a  long  time  without  the  necessity  of  removal  for  purifi- 
cation. 

Closed  Lever.' — For  the  general  practitioner,  this  modification 
of  the  lever  pessary  is  more  safe;  it  has  some  decided  advantages, 
and  some  disadvantages  when  compared  with  the  open  lever. 

It  is  four-sided,  and  its  curvature  may  be  single,  as  in  the  open 
lever,  or  double,  as  in  the  one  presently  to  be  described.  The 
former,  like  the  open  lever,  may  be  very  advantageously  em- 
ployed in  all  the  varieties  of  displacements.     The  douhle-curved'' 

'  See  diagram,  p.  415. 

2  Dr.  Holmes,  from  Soutli  Carolina,  one  of  our  former  pupils,  is  under  the  im- 
pression that  he  first  suggested  this  additional  curve. 


« 


420  TREATMENT — LEVER    PESSARIES. 

closed  lever  is  equally  advantageous,  and  is  preferable,  as  being 
less  liable  to  press  injuriously  on  the  bladder  or  urethra.  Its 
leverage  is  more  powerful,  as  it  is  longer,  and  as  the  tissues  ante- 
rior to  the  uterus  do  not  sink  so  much  between  the  sides  of  the 
pessary  as  in  the  open  lever.  Hence,  the  author,  for  some  time 
past,  has  given  it  the  preference.  Its  curves  may  be  named  the 
greater  and  the  less  ;  the  former  may  be  regarded  as  perfectly 
similar  to  that  of  the  open  pessary,  but  the  other  extremity  is 
slightly  bent  in  the  opposite  direction,  so  that  when  the  instru- 
ment is  viewed  laterally  its  curves  resemble  somewhat  those  of 
the  letter  S;  and,  for  the  purpose  of  distinction  from  the  open 
or  U  pessary,  this  may  be  termed  the  closed  or  the  S  pessary.  It 
has  also  been  termed  by  instrument  makers  the  "  hoiv'''  pessary. 
AVhen  introduced,  it  acts  similarly  to  the  open  lever,  as  an  ele- 
vator and  a  supporter.^ 

In  most  cases,  at  the  commencement  of  the  treatment,  especially 
when  there  is  a  rigid  and  short  vagina,  and  the  uterus  not  very 
movable,  the  extremity  iviih  the  smcdl  curve  should  be  placed  under 
the  uterus,  with  its  convexity  towards  the  posterior  surface  of  the 

'  Since  the  first  publication  of  tliis  work  in  1860,  several  modifications  of  the 
"  lever"  or  "  bow"  jiessary  have  been  made  iu  Europe  and  America.  Dr.  Churchill, 
of  Dublin,  in  cases  of  relaxation  of  the  vagina,  has  had  a  pessary  constructed  with 
two  bars  instead  of  one  in  front  of  the  uterus,  in  order  to  support  the  vagina.  Dr. 
Priestley,  of  London,  has  also  modified  it,  but  in  what  exact  manner  we  are  unin- 
formed. In  this  country  one  modification,  which  we  have  seen,  consists  in  having 
the  anterior  and  the  posterior  bar  curved,  instead  of  straight,  so  as  to  accommodate, 
it  is  said,  the  convexities  of  the  urethra,  the  rectum,  or  the  uterus,  while  the  whole 
instrument  is  comparatively  long.  This  last  proceeds  upon  an  erroneous  principle 
that  pressure  must  be  made  on  the  above  named  tissues.  A  good  lever  pessary, 
when  properly  arranged,  makes  no  pressure  upon  the  urethra,  rectum,  or  uterus  ; 
it  rests  on  the  posterior  wall  of  the  vagina,  is  movable  with  the  uterus,  and  at  the 
same  time  allows  of  its  natural  motions.  Its  extremities  do  not  impinge  uncom- 
fortably on  any  tissue.     The  lever  pessary  is  not  a  "  prop." 

Dr.  Scattergood  has  also  proposed  a  modification,  which  acts  on  the  same  im- 
proper principle.  This  consists  in  making  the  instrument  longer  and  less  curved, 
while  the  sides  are  made,  each  of  two  pieces  ;  the  anterior  or  lower  portions  being 
solid,  the  posterior  or  upper  portions  being  hollow  cylinders,  into  which  the  lower 
or  solid  cylinders  can  be  readily  i-eceived.  These  hollow  cylinders  contain  springs, 
so  that  the  length  of  the  instrument  will  be  diminished  or  increased  in  proportion 
to  the  degree  of  pressure  on  the  extremities  of  the  instrument.  The  idea  is  in- 
genious, but  the  principle  on  which  the  modification  is  founded  is  erroneous.  We 
repeat,  there  should  be  no  pressure  of  any  consequence  on  the  extremities  of  the 
instrument,  whether  tlie  lever  be  open  or  closed. 


CLOSED    LEVER. 


421 


CLOSED    LEVER    WITH    THE    SMALL    C0KVE    BEHIND IN    POSITION, 


CLOSED    LEVEE    WITH    THE    SMALL    CURVE    BEFORE IN    POSITION. 


422  TREATMENT — LEVER    PESSARIES. 

retroverted  uterus,  and  its  concavity  towards  the  rectum;  tlie 
concavity  of  the  greater  curvature  will  be  in  front  towards  the 
uterus,  and  the  convexity  towards  the  j)erineum.  Then  the 
index-finger,  pressing  on  the  lower  portion  of  the  pessary,  should 
cause  the  instrument  to  glide  slowly  between  the  rectum  and 
the  uterus ;  and  afterwards,  by  depressing  the  lower  extremity 
towards  the  perineum  and  rectum,  the  fundus  and  body  will  be 
raised  as  when  the  open  lever  is  employed.  The  advantage  in 
this  case  is,  that  the  convexity  of  the  small  curve  presents  a 
broader  surface  towards  the  irritable  tissue  of  the  uterus,  and  is 
therefore  less  likely  to  give  pain ;  on  the  contrary,  however,  rather 
more  pressure  is  made  towards  the  sacrum,  which  may  occasion- 
ally be  an  inconvenience. 

After  some  days,  when  the  uterus  has  yielded  to  this  pressure, 
the  pessary  may  be  removed,  and  reintroduced,  so  that  the  con- 
cavity of  the  large  curve  shall  be  towards  the  uterus  behind,  and 
the  convexity  of  the  small  curve  in  front  of  the  uterus  and  under 
the  bladder.  Cit  now  acts  much  more  powerfully  as  a  lever,  and 
care  must  be  taken  that  it  does  not  press  against  the  uterus  be- 
hind.' Under  these  circumstances,  the  lever-like  action  is  greater, 
in  proportion  to  its  size,  than  the  open  pessary ;  as,  the  small  cur- 
vature and  the  bar  in  front  of  the  uterus  present  a  larger  surface  to 
the  superincumbent  pressure,  depressing  the  anterior  or  long  arm 
of  the  lever  more  forcibly  towards  the  perineum,  and,  of  course, 
elevating  proportionably  the  upper  extremity  or  short  arm  of  the 
lever. 

This  increase  of  power,  and  the  comparative  safety  of  the 
closed  lever,  there  being  no  points  by  which  dangerous  pressure 
might  carelessly  be  made  on  the  tissues,  are  its  chief  advantages. 
The  objections,  as  compared  with  the  open  lever,  are,  that  it  is 
more  painful  to  introduce  and  to  remove,  more  liable  to  press  on 
the  bladder  and  urethra,  giving  rise  to  dysuria,  or  even  obstruc- 
tion, and  does  not  allow  of  such  ready  egress  and  entrance  of 
fluids,  etc.,  to  the  uterus.  Notwithstanding  these  minor  objec- 
tions, it  is  the  most  valuable  instrument,  from  its  great  power  as 
a  lever,  especially  when  there  is  much  resistance  to  the  replacing 
of  the  uterus.  In  virgins,  also,  the  closed  lever  is  preferable,  as 
a  narrow  open  lever  is  not  easily  introduced,  owing  to  the  thick- 
ness of  the  perineum  and  the  tonicity  of  the  vagina. 


INTRODUCTION    OF    OPEN    LEVER. 


423 


INTRODUCTION  AND  REMOVAL. 

Introduction  of  Open  Lever. — The  introduction  of  tlie  open 
lever  is  comparatively  very  easy,  and  seldom  painful,  in  women  who 
have  had  children,  if  two  or  three  rules  be  observed.  Let  the 
woman  be  placed  on  her  back,  with  her  limbs  flexed  and  her  feet 
near  the  edge  of  the  bed ;  this  is  the  best,  and  almost  the  only,  suit- 
able position  for  all  examinations  and  operations  in  displacements. 

The  instrument  being  anointed,  the  practitioner  should  hold  it 
in  his  right  hand,  with  the  points  downwards  towards  the  bed, 
the  convex  part  of  the  instrument  being  towards  the  left  thigh  of 
the  patient,  and  the  concave  towards  the  right.  The  labia  being 
now  cautiously  separated,  the  extremity  of  the  right  horn,  which 
is.  now  also  the  upper  one,  should  be  passed  into  the  orifice  of  the. 


IXTRODUCTION     OF     OPEN     LEVER. 


vagina,^  and  be  pushed  downward  on  the  plane  of  the  perineum, 
a  little  to  the  right  of  the  median  line,  until  the  whole  right  horn 


'  Of  course,  the  orifice  of  the  urethra  should  be  avoided.  This  caution  seems 
to  be  necessary,  as  Dr.  Horatio  R.  Storer,  of  Boston,  has  reported  in  the  Medical 
Record  of  July  15th,  1868,  a  case  in  which  an  open  lever  pessary  had  been  intro- 
duced into  the  bladder.  At  the  expiration  of  five  days,  Dr.  Storer  succeeded  in 
removing  it  without  incision,  by  his  finger,  after  dilating  the  urethra.  The  blunt 
hook  represented  (p.  393)  at  one  extremity  in  the  diagram  of  the  small  extractor, 
would  be  a  valuable  assistant  on  such  an  occasion. 


424  TREATMENT — LEVER    PESSARIES, 

disappears  in  the  vagina ;  tlie  bar  is  thus  brought  to  the  top  of 
the  arch  of  the  pubis,  and  on  the  left  side  of  the  urethra.  The 
left  horn  will  be  found  extending  externally  along  the  perineum 
towards  or  beyond  the  anus,  and  some  care  is  occasionally  re- 
quired to  see  that  it  does  not  pass  through  this  orifice  into  the 
rectum.  The  bar  of  the  instrument  is  now  to  be  pushed  directly 
into  the  vagina  till  the  whole  has  entered,  so  that  the  right  horn 
of  the  pessary  is  within  and  the  other  without  the  vagina,  and 
the  bar  against  the  left  ramus  of  the  pubis.  A  combined  opera- 
tion is  now  demanded,  in  order  to  depress  the  bar  on  the  left  side 
of  the  vagina  until  it  gets  under  the  cervix  uteri.  This  combined 
manoeuvre  consists  in  placing  the  index  finger  of  the  right  hand 
on  the  bar,  now  at  the  orifice,  and  pressing  it  firmly  but  steadily 
downwards,  on  the  left  wall  of  the  vagina,  and  within  the  rami 
of  the  pubis  and  ischium.  At  the  same  moment,  within  the 
thumb  of  the  right  hand  (or  the  fingers  of  the  left),  the  extremity 
of  the  left  horn  is  to  be  slowly  elevated  from  the  perineum  near 
the  anus,  over  the  right  labia  and  nyraphse  to  the  right  ramus 
of  the  pubis,  where  it  will  now  readily  enter  the  orifice,  being  of 
course  preceded  by  the  whole  left  horn  of  the  instrument.  By 
this  movement  the  whole  pessary  is  made  to  revolve,  so  that  one 
extremity  (that  of  the  right  horn)  is  the  first,  and  the  other 
extremity  (that  of  the  left  horn)  is  the  last  portion  that  enters 
the  vagina.  The  bar  will  now  generally  be  found  against  the 
posterior  part  of  the  retroverted  uterus,  and  may  give  pain. 
This  is  to  be  obviated  by  the  index-finger  depressing  the  bar 
against  the  rectum,  as  much  as  is  convenient,  and  allowing  the 
extremities  of  the  horns  to  rise  in  front,  close  to  the  bladder. 
This  finishes  the  introduction  of  the  pessary ;  it  will  be  accom- 
plished most  readily  when,  with  sufficient  breadth  of  the  instru- 
ment, the  length  of  the  horns  is  comparatively  short. 

Removal  of  Open  Lever. — Its  removal  is  to  be  accomplished 
by  reversing  the  manoeuvre  by  which  it  was  introduced.  The 
woman  being  placed  in  the  same  position  as  formerly  described, 
the  index-finger  of  the  right  hand,  well  anointed,  is  to  be  passed 
into  the  vagina  to  the  left  horn,  and  carefully  insinuated  between 
it  and  the  side  of  the  pelvis.  This  horn  can  be  slowly  pressed, 
so  as  to  get  the  whole  instrument  into  an  oblique  position.  The 
finger,  passed  over  this  horn,  can  now  draw  it  downward  until  its 
extremity  comes  to  the  orifice  of  the  vagina,  and  as  soon  as  it 
completely  emerges,  it  should  be  made  to  ascend  in  front  of  the 


REMOVAL    OF    OPEN    LEVER. 


425 


pubis,  passing  over  in  succession  tlie  riglit  nympha  and  labium 
externum.  The  traction  may  now  be  continued  by  moving  the 
finger  along  the  horn  to  the  bar,  and  stretching  the  posterior 
margin  of  the  vagina,  so  that  the  bar,  and  subsequently  the  right 
horn,  successively  emerge.  The  extremity  of  the  right  horn  is, 
by  this  evolution,  the  last  portion  delivered. 


REMOVAL    OF     OPEN     LEVER. 


Large  pessaries  can  thus  be  introduced  and  removed  with  com- 
paratively little  pain,  in  cases  where  the  vaginal  orifice  is  so  con- 
tracted, that  a  closed  lever  of  the  same  breadth  could  not  be 
employed.  These  open  levers  are  also  as  easy  of  introduction 
as  the  spring  pessary.  We  have  often  introduced  an  open  lever, 
and  allowed  patients  to  wear  it  for  days,  without  their  having  been 
conscious  of  its  introduction  or  subsequent  presence,  and  they 
were  much  surprised  when  informed  of  the  circumstance. 

Introduction  of  Closed  Lever, — The  introduction  of  the 
closed  lever  is  much  more  painful  in  proportion  to  its  magnitude, 
as  it  must  enter  presenting  the  whole  of  its  transverse  diameter. 

If  it  be  desirable  that  the  extremity,  with  the  small  curve, 
should  be  first  introduced,  it  should  be  directed  to  the  orifice  of 
the  vagina,  somewhat  obliquely,  so  that  the  convexity  of  the 
small  curve  should  be  anterior,  and  the  concavity  posterior ;  the 
labia  and  nymphse  being  carefully  separated,  the  bar  of  the  pessary 
should  be  pressed  into  the  orifice  so  that  one  edge  of  the  instru- 
ment is  anterior  and  to  the  left  of  the  urethra,  while  the  other  is 


426  TKEATMENT — LEVER    PESSARIES. 

posterior  and  to  the  right  of  the  raphe  of  the  perineum.  The 
whole  instrument  must  be  so  elevated  that  the  extremity  may  enter 
perpendicularly  to  the  opening  of  the  vagina.  By  firm  pressure 
downwards  against  the  perineum,  the  pessary  enters  the  vagina ; 
but  the  upper  extremity,  instead  of  passing  under  the  uterus,  ■ 
necessarily,  owing  to  the  large  curve,  rises  up  in  front  of  the  organ 
and  against  the  bladder.  Pressure,  often  quite  painful,  is  for  the 
time  made  on  the  neck  of  the  uterus;  the  practitioner,  therefore, 
hastens  to  introduce  his  finger  through  the  opening  of  the  pessary, 
and  to  press  down  the  upper  extremity  under  the  uterus  as  soon 
as  possible,  thus  affording  immediate  relief  to  the  pain. 

When  the  large  curve  is  to  be  introduced  first,  the  whole  ope- 
ration should  be  conducted  in  a  similar  manner,  excepting  that 
the  concavity  of  this  curve  should  be  directed  anteriorly,  and  the 
convexity,  posteriorly.  The  bar  should  be  directed  perpendicu- 
larly against  the  orifice  of  the  vagina,  and  the  whole  be  thus 
gradually  introduced,  great  care  being  taken,  by  a  finger  in  the 
vagina,  to  direct  the  upper  bar  under  the  uterus. 

Fixing  the  Instrument. — Much  attention'  should  be  paid  to  adjust 
the  instrument  properly  after  its  introduction  into  the  vagina,  and 
its  location  under  the  uterus.  If  it  be  thus  left,  especially  in 
cases  of  retroversion,  the  bar  would  often  impinge  painfully 
against  the  irritable  organ,  which  could  not  be  tolerated.  Hence, 
the  practitioner  should  take  time  to  gradually  work  the  upper  or 
superior  bar  between  the  uterus  and  the  rectum,  not  pressing 
upon  either  of  these  viscera,  and  therefore  giving  no  pain,  the 
vagina  gradually  elongating,  so  as  to  allow  the  pessary  to  ascend 
posteriorly.  This  object  cannot  always  be  attained  immediately; 
where  the  vagina  is  rigid,  unusually  short,  or  thickened,  time  is 
required,  and  the  form  of  the  pessary  is  gradually  varied  from  a 
lesser  to  a  greater  curvature.  Many  fail  in  the  use  of  the  pessary 
from  the  want  of  attention  to  this  rule  of  gradually  elongating 
the  vagina,  so  that  the  pessary  may  ascend  behind  the  uterus. 

Removal  of  Closed  Lever, — Its  removal  is  easily  effected  by  the 
practitioner,  but  with  more  or  less  pain  to  the  patient.  Since  a 
portion  of  the  instrument  is  behind  the  uterus,  the  instrument 
should  be  first  turned  obliquely,  and  then  the  traction  effort  being 
made,  one  edge  comes  out  of  the  vagina  towards  the  ramus  of 
the  pubis,  and  the  other  towards  the  perineum.  As  the  curves 
successively  pass,  the  instrument  should  be  allowed  to  rise  in 
front  of  the  pubis. 


GENERAL    EEMARKS.  427 


GENERAL  REMARKS. 


The  description  just  given  of  the  good  influences  of  the  lever 
pessary,  has  been  founded  on  the  supposition  that  the  uterus  is 
movable,  and  the  vagina  relaxed,  so  as  to  be  readily  elongated. 
It  has  been  stated  also  that  one  and,  perhaps,  the  great  difficulty 
of  treating  retroversion,  is  often  the  shortness  of  the  vagina,  and 
its  close  connection  with  the  posterior  lip  of  the  as  uteri,  so  that  no 
pessary  can  immediately  ascend  high  on  the  posterior  surface  of 
the  uterus;  this  is  especially  true  in  the  unmarried  and  those 
who  have  not  borne  children.  The  practitioner  must  not,  how- 
ever, be  discouraged  by  this  resistance  of  the  vagina.  The  vagina 
is  an  extensile  tube,  and  admits  of  enormous  distension  with 
impunity,  provided  such  distension  be  slowly  and  judiciously 
made,  so  as  not  to  excite  organic  irritation  or  inflammation.  The 
vagina  may  be  elongated  in  a  case  of  retroversion  by  beginning 
with  comparatively  a  small  pessary,  and  of  slight  curvature — 
even  a  flat  ring  is  often  valuable  to  begin  the  treatment.  By 
steady  pressure  between  the  uterus  and  rectum,  and  by  allowing 
the  instrument  to  be  worn  for  a  few  days,  something  is  gained. 
It  may  then  be  removed,  and  there  may  be  substituted  a  larger 
instrument  or  one  of  greater  curvature,  that  is,  of  more  power, 
for  the  power  of  these  levers  depends  more  on  their  curvature 
than  on  their  dimensions;  then  a  third,  still  more  powerful,  may 
be  employed,  and  so  on  in  gradual  or  rapid  succession,  in  propor- 
tion as  the  vagina  yields  and  the  fundus  rises,  or  the  comfort  and 
sensibilities  of  the  patient  will  allow. 

These  sensations  should  always  be  regarded;  there  must  be 
too  much  pressure,  or  in  a  wrong  direction,  when  there  is  pain. 
The  tissues  in  some  patients  are  so  irritable  that  every  advance 
must  be  slow,  while  in  others  great  pressure  will  be  borne  with 
impunity.  Let  it  be  observed,  however,  that,  even  in  cases  of 
irritable  and  engorged  uterus,  pessaries  can,  with  care  and  pru- 
dence, be  almost  universally  tolerated.  "We  have  so  often,  by 
means  of  pessaries,  afforded  partial  or  even  complete  relief  to 
patients  who  had  been  bedridden  from  irritable  uterus — even  to 
those  with  whom  mere  motion  in  bed  was  impracticable,  and  any 
touching  of  the  vulva  and  vagina  seemed  intolerable,  in  whom 
spasms  of  the  vagina  and  the  pelvic  muscles  were  often  intense, 


428  TREATMEN-T  —  LEVER    PESSARIES. 

and  where  tbe  sympathetic  irritations  were  so  great  as  to  result 
in  spasms  and  convulsions — that  we  speak  and  write  with  confi- 
dence. The  irritability  of  the  orifice  and  the  canal  of  the  vagina 
will  gradually  diminish ;  operations  at  first  painful  are  soon  not 
dreaded,  and  the  uterus  replaced  and  sustained,  eventually  loses 
its  abnormal  sensibility.  Even  in  many  cases  where  the  vagina 
has  been  contracted  by  inflammation,  and  where  bridles  or  cica- 
trices have  formed,  steady  pressure,  beginning  with  a  small 
instrument  followed  by  a  larger,  will  be  effectual  in  overcoming 
these  difficulties,  so  that  the  uterus  may  be  properly  supported. 

By  steady  perseverance  in  elevating  the  uterus  by  means  of 
frequent  changes  in  the  form  and  size  of  the  instruments,  as  the 
tissues  yield  before  their  influence,  even  more  poioerful  obstacles 
than  the  resistance  of  the  vagina  may  be  overcome.  As  exam- 
ples of  these  obstacles,  we  may  mention  those  arising  from 
hypertrophy;  from  induration;  from  tumors  in  the  interior,  in 
the  substance,  or  on  the  exterior  of  the  uterus;  from  the  pressure 
of  tumors  of  the  ovaries,  or  the  mesentery;  from  tympanites  and 
dropsies ;  and  from  the  connecting  tissues  of  the  uterus  having 
become  rigid  and  fixed  in  their  unnatural  position  in  consequence 
of  the  lapse  of  years,  or  it  may  be  from  firm  adhesions  having 
occurred  between  the  opposing  peritoneal  surfaces.  Even  in  such 
cases,  "  nil  desperandum"  should  be  the  motto  of  the  practitioner. 
The  principle  being  correct,  perseverance  is  demanded,  and  the 
reward  will  be  proportionate  to  our  endeavors.  Such  are  the 
happy  results  which  may  be  expected  from  the  use  of  the  lever 
pessaries,  when  cautiously  and  judiciously  employed. 

The  principle  of  their  action  being  borne  in  mind,  there  may 
and  frequently  must  be  made  many  modifications  of  the  form  and 
size  of  these  curved  pessaries,  that  they  may  be  suited  for  the 
peculiarities  of  the  individual  cases.  Drawings  of  two  of  these 
varieties^  have  been  exhibited,  one  rectangular,  the  other  circu- 
lar, and  both  furnished  with  flat  circular  disks  from  six  to  eight 
lines  in  diameter.  It  should  always  be  remembered  that,  as  no 
physician  is  qualified  to  prescribe  powerful  medicines,  such  as 
calomel  and  opium,  without  exercising  his  judgment  in  adapting 
them,  as  to  their  doses,  time,  and  manner  of  exhibition  to  the 
ever  varying  condition  of  his  patient ;  so  no  one  ought  to  under- 

'  See  diagrams,  p.  415. 


SHORTNESS    OF    VAGIN"A,   ETC.  429 

take  the  surgical  treatment  of  displacements  of  tlie  uterus,  with- 
out constantly  exercising  much  discrimination  in  the  use  of  his 
powerful  and  even  dangerous  instruments.  If  the  knife  of  the 
surgeon  can  do  mischief,  so  may  his  bougies,  his  bandages,  or 
even  his  fingers ;  and  he  is  equally  bound  to  be  careful  in  the 
employment  of  all  of  them.  And  besides,  the  idea  that  the  mere 
introduction  of  a  pessary  within  the  vulva  is  "per  se,"  of  itself, 
sufiicient  for  the  elevation  and  sustentation  of  the  uterus  is  ab- 
surd, the  indulgence  of  which  has  wrought  mischief  to  the 
patients  and  discredit  to  the  profession. 

If  the  lever  pessary  be  very  valuable,  it  can  also  he  very  injurious. 
Perhaps  whatever  is  most  efficient  for  good  may  the  more  readily 
be  perverted  to  evil. 

All  the  objections,  formerly  detailed  against  pessaries  in  gene- 
ral, may  be  predicated  of  lever  pessaries.  They  have  been  made 
of  perishable  materials,  too  large,  too  much  or  too  little  curved, 
and  have  thus  originated  pain,  inflammation,  and  their  conse- 
quences. Moreover,  it  may  be  freely  confessed,  that  the  dangers 
from  the  lever  are  rather  greater  than  from  many  other  pessaries, 
even  when  the  material  is  unexceptionable.  Their  power  is 
greater,  and  of  course  more  care  is  demanded.  A  flat  disk,  a  flat 
ring,  or  a  ball  pessary  introduced  into  the  vagina,  may  not  excite 
irritation,  while  a  curved  supporter  of  no  larger  size  may  press 
painfully  on  the  uterus  or  the  walls  of  the  vagina.  In  retrover- 
sion, it  may  turn  up  against  the  body  of  the  uterus  too  suddenly, 
indeed  will  generally  do  so,  to  the  discouragement  of  all,  if  care 
be  not  taken  to  elongate  the  vagina  and  press  the  instrument 
steadily  between  the  uterus  and  the  rectum,  so  as  not  to  impinge 
anteriorly  against  the  uterus,  or  posteriorly  against  the  rectum 
or  the  nerves  of  the  pelvis. 

If  the  instrument  makes  pressure  against  the  sacral  nerves,  it 
often  excites  severe  neuralgia  in  various  parts  of  the  body,  usually  N^ 
so  quick  and  transitory  as  to  be  called  by  patients  "  lightning- 
pains."  They  resemble  the  pain  produced  by  biting  on  a  dis- 
eased tooth,  or  striking  the  ulnar  nerve  at  the  elbow.  Facts  of 
this  kind  have  been  so  numerous  and  so  wonderful  in  the  author's 
experience  as  to  justify  a  little  detail,  advantageous  perhaps  to  the 
physiologist  and  anatomist,  as  well  as  to  the  practitioner. 

In  various  operations,  especially  in  cases  of  retroversion,  while 
endeavoring  to  avoid  the  uterus  in  pressing  the  pessary  between 


430  TREATMENT  —  LEVER    PESSARIES. 

it  and  the  sacrum,  some  nervous  twig  or  larger  branch  has  per- 
haps been  touched,  and  is  followed  bj  an  instantaneous  exclama- 
tion from  the  patient,  indicating  the  severity  and  suddenness  of 
the  pain.  It  is  as  transitory  as  it  is  sudden.  The  exclamation  is 
as  speedily  followed  by  the  smile  of  astonishment  at  the  complete 
suspension  of  the  suffering. 

(■'  The  location  of  these  pains,  as  indicated  by  the  sensation,  is 
various,  and  may  give  rise  to  interesting  and  productive  specula- 
tions to  the  anatomist  and  physiologist.  They  are  most  fre- 
quently, perhaps,  referred  to  the  back  or  the  hip — sometimes  to 
the  left  hip  when  the  pressure,  apparently,  is  made  on  the  right 
of  the  rectum,  and  the  reverse — not  unfrequently  to  the  iliac 
fossa,  to  the  groin,  to  the  inside  of  the  thigh;  very  frequently  to 
the  knee,  the  calf  of  the  leg,  the  instep,  and  the  heel,  especially 
directly  under  the  os  calcis.  The  reflex  influence  is  sometimes 
in  the  opposite  direction,  evidently  through  the  spinal  marrow ; 
and  the  pain  is  often  referred  to  the  neck,  the  shoulder,  the  hypo- 
chondriac region,  &c.  "Oh,  doctor,"  exclaimed  a  cheerful,  and 
intelligent  lady,  "you  hurt  my  neck — my  shoulder — my  side — 
my  knee;"  and  all  this  in  rapid  succession,  each  spot  being  re- 
lieved before  the  other  was  involved.  Another  exclaimed,  on  the 
removing  of  an  instrument,  "Doctor,  you  hurt  me." — "  Where?" 
— "At  the  top  of  my  head.'^ 

Indeed,  it  would  seem  that  there  is  hardly  a  portion  of  the 
economy  which  is  not  represented  by  a  sacral  nerve,  an  irrita- 
tion of  which  may  have  a  response  from  a  distant  tissue  or  organ. 
So,  also,  disturbances  of  the  viscera,  spasmodic  croup,  nervous 
coughs,  asthmatic  symptoms  and  oppression  in  breathing,  often 
arise  from  the  same  cause,  as  also  palpitation  of  the  heart,  nausea, 
etc.  The  reverse  of  these  observations  also  confirms  the  truth  of 
the  statement.  When  some  of  these  morbid  sensations  have 
existed,  they  occasionally  disappear  instantaneously  during  the 
elevation  of  the  uterus.  The  pain  in  the  head,  the  shortness  of 
breath,  the  stricture  around  the  chest,  and  the  nausea,  have  thus 
disappeared ;  or  the  neuralgia  in  the  neck,  in  the  shoulder,  in  the 
hypochondriac,  the  umbilical,  or  the  iliac  region,  in  the  knee,  or 
in  the  foot,  has  thus  quickly  vanished. 

These  and  innumerable  analogous  facts  are  interesting,  and  the 
general  explanation  is  easy  from  the  known  unity  of  the  cerebro- 
spinal apparatus.     But,  why  a  pain  at  the  top  of  the  foot  or  at 


NEURALGIA    FROM    PRESSURE    OX    SACRAL    NERVES.      431 

the  base  of  the  heel,  at  the  apex  of  the  shoulder  or  in  the  region 
of  the  liver  (so  often  and  injuriously  considered  as  the  certain 
representative  of  "  liver  disease"),  or  in  the  region  of  the  spleen, 
should  exist  from  uterine  and  sacral  irritation,  while  other  por- 
tions of  the  body  are  perfectly  exempt  from  uneasiness,  demands 
a  more  accurate  anatomy  and  physiology  than  has  even  yet  been 
evolved. 

The  three-sided  or  open  pessary  has  been  objected  to  from 
the  danger  of  the  horns  pressing  on  the  tissues,  and  producing  in- 
flammation and  ulceration.  The  danger  exists,  and  should  be 
guarded  against  by  taking  care  that  the  instrument  be  not  too 
long,  and  that  the  extremities  of  the  horn  make  no  pressure,  for 
then  this  pessary  would  have  all  the  disadvantage  of  a  fixed  pes- 
sary— it  would  no  longer  be  movable,  or  even  allow  motion  to 
the  uterus.  Neither  should  the  practitioner  allow  the  instrument 
to  twist  so  that  the  points  press  laterally,  for  then  the  instrument 
is  out  of  position,  and  does  no  good ;  nor  should  they  press  against 
the  anterior  walls  of  the  vagina,  for  then  inflammation  and  ulcera- 
tion might  arise  and  penetrate  the  bladder.  Of  course,  also,  the 
points  of  the  horns  should  never  be  allowed  to  turn  posteriorly, 
as  the  inflammation  and  ulceration  then  excited  might  penetrate 
the  peritoneum,  endangering  even  the  life  of  the  patient. 

All  these  dangers  may  be  easily  prevented  by  a  little  care. 
The  extremities  of  the  horns,  when  the  instrument  is  in  proper 
position,  ought  not  to  advance  towards  the  bladder,  but  rather 
should  recede  on  the  bearing  down  efforts  of  the  patient.  The 
practitioner,  after  the  adjustment  of  the  instrument,  should  place 
his  finger  on  one  extremity,  and  request  his  patient  to  bear 
down :  if  it  recedes,  or  remains  stationary,  he  may  be  satisfied  ; 
if,  on  the  contrary,  it  advances,  and  presses  on  his  finger  or  the 
bladder,  an  alteration  becomes  necessary.  This  arises  because 
the  pressure  downwards  of  the  body  and  fundus  uteri  is  too  power- 
ful for  the  pessary,  or,  what  amounts  mechanically  to  the  same 
thing,  the  resistance,  whatever  be  the  cause,  is  not  overcome. 
The  short  arm  of  the  lever  descends,  and  the  long  arm,  or  that 
in  front  of  the  uterus,  ascends.  A  change,  in  such  cases,  should 
be  made  to  a  shorter  or  a  less  curved  pessary,  until  the  vagina 
or  the  uterus  yield  sufficiently  to  allow  of  a  more  powerful  in- 
strument.    In  other  words,  the  rule,  that  the  pessary  is  to  be 


432  TREATMEXT — LEVER    PESSARIES. 

worn  without  nervous  or  organic  irritation,  should  always  be  re- 
membered.,. 

The  supposed  danger  from  the  extremities  may  be  diminished 
by  the  addition  of  the  flat  disks,  on  their  concave  surface,  by 
which  the  pressure  is  transferred  to  these  disks,  rather  than  to 
the  extremities  of  the  horns,  and  by  which  also  the  power  of  the 
instrument  as  a  lever  is  increased ;  so  that  a  comparatively  smaller 
one  will  answer. 

Another  objection  presented  is,  that  pressure  will  he  made 
against  the  bladder  and  the  rectum^  so  as  to  excite  dysuria  or  tenes- 
mus, or  to  cause  obstruction.  This  arises  from  the  same  cause, 
namely,  too  much  resistance  to  the  ascent  of  the  fundus,  and  de- 
mands, therefore,  an  alteration  in  the  size  or  especially  in  the 
curvature,  so  as  to  elevate  the  uterus  and  relieve  the  viscera, 
whether  in  front  or  behind. 

The  great  difficulty  in  managing  the  lever  pessary  is,  its  tend- 
ency to  rotate^  so  as  to  become  more,  or  less  transverse  in  the 
vagina.  This  accident,  when  it  occurs,  is  unfortunate,  as  the 
pressure  becomes  uncomfortable,  or  even  painful,  and  the  symp- 
toms of  displacement  return,  inasmuch  as  the  uterus  now  will 
have  but  a  trifling  support,  and  the  fundus  falls  down  at  once  into 
the  hollow  of  the  side  of  the  pessary.  A  globular,  a  flat  circular 
ring,  or  disk  pessary,  may,  of  course,  rotate  in  any  direction  with 
impunity ;  they  always  present  the  same  diameters  and  the  same 
surfaces  to  the  vagina  and  the  uterus.  Not  so  with  the  lever,  on 
account  of  the  peculiarity  of  its  shape,  its  usefulness  depends  on 
its  not  rotating ;  the  bar  must  be  posterior  and  behind  the  uterus, 
for  comfort  and  efi'ect. 

The  cause  of  the  rotation  is  evident,  being  not  merely  from  the 
resistance  of  the  vagina  posteriorly,  but  from  the  pressure  of  the 
uterus,  which  is  by  no  means  always  in  the  middle  line ;  for  very 
frequently  the  fundus  is  found  towards  the  right,  sometimes 
towards  the  left  ischiatic  foramen.  The  chief  cause  is,  however, 
the  unequal  pressure  of  the  rectum,  which  always  lies  to  the  left 
of  the  median  line  of  the  sacrum,  and  is  constantly  and  sometimes 
greatly  distended  by  feculent  accumulations.  The  bearing-down 
efforts  of  the  patient  when  such  distension  exists,  as  well  in 
standing  and  walking  as  in  the  act  of  defecation,  will  sufficiently 
explain  why  rotation  should  sometimes  occur.  Indeed,  it  is 
wonderful,  that  the  pessary  should  ever  remain  permanent,  under 
all  the  irregular  pressure  to  which  it  is  subjected. 


OBJECTIONS    MADE    TO    LEVER    PESSARIES.  433 

This  predispoeition  to  rotation  may  be  counteracted  sometimes 
by  increasing,  to  a  certain  extent,  the  breadth  or  the  length  of 
the  pessary,  or  by  augmenting  its  curvature,  and  occasionally  by 
employing  instruments  furnished  with  the  flat  disks  on  the  horns, 
which  also  will  contribute  to  prevent  rotation.  Much  may  also 
be  accomplished  by  simple  pressure  against  the  instrument,  so  as 
to  imbed  it  more  completely  in  the  vagina  and  behind  the  uterus. 
Indeed,  when  the  fundus  uteri  completely  yields  to  the  pessary, 
there  is  comparatively  little  danger  of  displacement  of  the  instru- 
ment. 

Similar  objections,  although  in  a  minor  degree,  may  be  made 
against  the  closed  lever ;  its  too  great  size  or  curvature  may 
produce  pain ;  pressure  against  the  walls  of  the  vagina  may  be 
so  inordinate  as  to  excite  inflammation,  followed  by  seroid,  or 
mucoid,  or  purulent  discharges,  also  by  ulceration,  which,  if 
neglected,  will  penetrate  the  surrounding  tissues.  Sometimes  the 
vagina  will  grow  over  the  pessary,  partly  or  completely  imbed- 
ding the  instrument.  All  these  accidents  are  owing  either  to  the 
neglect  of  the  patient  or  the  inattention  of  the  practitioner.  The 
pressure  should  never  be  so  great  as  to  excite  the  least  degree  of 
vaginitis. 

Another  danger  arises  from  the  false  idea  that  the  lower  part 
of  the  pessary  should  press  against  the  bones  of  the  pubis,  and, 
of  course,  pain  and  inflammation  would  follow.  The  instrument 
should  never  impinge  firmly  against  any  tissue,  especially  where 
such  tissues  are  near  the  bones;  this  is  the  real  fault  of  the  modi- 
fication of  the  lever  pessary  by  Mr.  Scattergood,  who  places  a 
spring  in  each  arm  of  the  pessary,  that  its  length  may  be 
accommodated  to  that  of  the  vagina.  The  pessary  should  always 
be  movable  with  the  uterus. 

Of  course,  in  all  cases  of  displacement  of  the  uterus,  complicated 
toith  uterine^  ovarian^  or  other  tumors^  peculiar  difficulties  may  be 
experienced.  Patience  and  perseverance,  perhaps  aided  by  some 
modification  in  the  form  of  the  instrument,  will  almost  univer- 
sally overcome  such  obstacles. 

The  patient  should  be  hept  for  some  time  under  the  supervision  of 
the  physician,  even  after  all  the  symptoms  of  displacement  have 
entirely  disappeared.  It  is  generally  found  that  if  the  woman 
can  walk  two  or  three  miles  a  day  for  ten  consecutive  days  with- 
out any  uneasiness  or  difficulty,  and  without  displacement  of  the 
28 


434  TREATMENT — LEVER    PESSARIES. 

Uterus  or  pessary,  she  may  be  regarded  as  quite  independent. 
Sometimes  even  after  this  test,  some  partial  displacement  of  the 
instrument  may  ensue ;  but  we  continually  examine  patients  who 
have  worn  these  supporters  from  one  to  five  years,  without  any 
change  of  location  in  the  pessary. 

Conclusions. — The  author  has  thus  endeavored  to  present  fairly 
the  importance  of  pessaries  in  the  treatment  of  displacements,  the 
objections  against  their  employment  in  general,  and  the  peculiar 
advantages  and  disadvantages  of  the  more  important  varieties. 
He  has  striven  to  demonstrate  the  failure  of  all  the  forms,  except- 
ing the  intra-uterine  and  the  lever  pessary,  in  fully  replacing  and 
sustaining  the  fundus  of  the  uterus.  He  has  attempted  to  prove 
that  although  the  intra-uterine  pessary  may,  mechanically  con- 
sidered, be  more  directly  efficient  than  the  lever,  yet  the  objec- 
tions against  its  use  are  insuperable ;  that  its  temporary  employ- 
ment, even  if  the  patient  be  at  rest,  is  fraught  with  danger ;  that 
it  cannot  be  tolerated  in  cases  of  inflammation  of  the  cervix  and 
OS  uteri,  or  in  cases  of  irritable  and  sensitive  uterus,  especially 
when  attended  by  leucorrhoea  or  menorrhagia ;  that  it  must  be 
occasionally  removed,  when,  of  course,  the  displacement  .will  re- 
turn ;  that  its  employment  is  incompatible  with  connubial  rites ; 
and  finally,  that  its  use  for  a  few  weeks,  or  a  few  months,  will 
very  rarely  be  adequate  for  a  radical  cure,  as  it  does  not  allow 
sufficient  time  for  the  contraction  of  the  elongated  ligaments. 

The  lever  pessary  will  more  slowly  accomplish  the  restoration 
of  the  displaced  organ,  but,  eventually,  with  equal  certainty.  It 
does  not  necessarily  produce  any  irritation,  organic  or  nervous, 
or  any  leucorrhoea,  menorrhagia,  inflammation,  etc.  It  can  be 
worn  at  all  times,  night  and  day;  it  interferes  with  no  motion, 
and  no  function;  the  patient  has  no  attentions  to  pay  to  it, 
excepting  a  daily  vaginal  wash ;  she  may,  and  often  does  forget 
its  presence,  can  enjoy  her  connubial  pleasures,  can  move  about 
in  society  without  anxiety,  is  free  from  local  and  general  nervous 
irritation,  from  corporeal,  intellectual,  and  spiritual  disturbance ; 
and  her  physician  may  hope  that,  the  uterus  being  perfectly 
sustained,  the  ligaments,  now  free  from  every  counteracting  influ- 
ence, will  continue  to  contract  to  their  normal  length,  and  acquire 
their  original  tonicity,  so  that  a  permanent  cure  may  be  eJffected, 
or  that  pregnancy  ensuing,  the  continued  use  of  the  pessary  will 
preserve  his  patient  from  those  irritations  so  frequently  excited 
by  displacements,  and  so  apt  to  result  in  abortions. 


PROLAPSUS  —  ANTEVEKSION.  435 


CHAPTER    VII. 

TREATMENT    OF    THE   VARIETIES   OF   DISPLACEMENTS. 

In  the  preceding  pages,  many  directions  and  allusions  have 
been  made  to  the  treatment  of  the  different  forms  of  displacement, 
and  especially  to  the  modifications  occasionally  requisite  to  fulfil 
particular  indications.  In  the  author's  experience,  the  lever  pes- 
sary has,  with  few  exceptions,  answered  for  every  displacement ; 
even"  in  retroversion  and  retroflexion  of  the  uterus,  it  has  satis- 
fictorilj  fulfilled  the  indication  of  restoring  and  keeping  the 
fundus  in  position. 

VARIETIES. 

Prolapsus. — In  prolapsus^  it  is  an  easy  matter  to  elevate  the 
organ  in  the  direction  of  the  axis,  which,  according  to  the  definition 
already  given,  nearly  corresponds  in  such  cases  to  the  axis  of  the 
superior  strait.  To  accomplish  this,  and  to  support  it  when  thus 
elevated,  some  form  of  a  ring  pessary  is  essential.  Every  other 
variety  would  make  pressure  on  the  cervix,  increasing  or  causing 
flexion,  and  producing  or  augmenting  irritation  or  inflammation 
at  the  mouth  of  the  womb.  For  these  reasons,  the  disk  pessary 
of  Dewees,  as  already  remarked,  is  decidedly  injurious  in  these 
cases  of  prolapsus,  and  so  also  the  ball,  the  cylinders,  etc.  The 
curved  ring  or  lever  seems  to  be  preferable  even  to  the  flat  ring, 
as  it  is  accommodated  to  the  natural  curves  of  the  vagina,  allows 
mobility,  and  makes  no  pressure  on  the  rectum  or  bladder,  while 
it  well  supports  the  uterus,  and  takes  away  all  pressure  from  its 
cervix. 

Anteversion. — In  anteversion,  the  lever  pessaries  answer  very 
well ;  for,  in  this  case,  the  uterus  resting  on  the  convex  surface  of 
the  lower,  or  the  long  arm  of  the  instrument,  is  thereby  elevated 


436      TREATMENT    OF    VARIETIES    OF    DISPLACEMENTS. 

from  the  pubis,  and,  by  tbe  pressure  from  above,  tlie  pessary  and 
the  uterus  glide  down  the  inclined  plane  of  the  perineum,  and 
thus  the  fundus  is  carried  still  further  from  the  pubis.  As  in  all 
ring  pessaries,  the  neck  is  protected  from  pressure  against  the 
walls  of  the  vagina. 

However,  almost  any  variety  of  pessary  may,  with  proper  atten- 
tion, answer  in  anteversion,  such  as  the  spherical,  the  conical,  the 
cylindrical,  the  flat  oval,  the  flat  disk,  the  flat  ring,  the  double  or 
plano-convex,  etc.,  as  they  all  have  the  effect  of  elevating  the  fun- 
dus of  the  uterus  from  its  position  behind  the  pubis.  Generally, 
in  the  spherical  pessary  also  no  injurious  pressure  is  made  in  such 
cases  on  the  os  and  labia  of  the  cervix.  Some  modification  of 
the  ring,  however,  is  preferable,  as  securing  the  safety  of  the  cer- 
vix from  all  pressure.  In  our  experience,  few  bad  consequences 
result  from  simple  anteversion  of  the  uterus,  and  it  is  so  manage- 
able, that  we  are  much  surprised  that  some  late  authors  speak  of 
its  being  so  intractable,  or  even  incurable,  that  no  measures  are 
adequate  to  its  relief,  especially  that  any  should  consider  it  justi- 
fiable to  contract  the  anterior  portion  of  the  vagina  between  the 
uterus  and  the  urethra  by  scarifications,  sutures,  etc.,  so  as  to  draw 
the  cervix  uteri  forward.  We  can  hardly  conceive  that  such  an 
operation,  requiring  much  dexterity,  and  involving  many  dangers, 
can  be  demanded,  or  that  it  could  usually  be  successful. 

In  anteversion  with  flexion  of  the  uterus,  a  ring  pessary  is  all- 
important,  as  it  alone  supports  the  uterus  at  the  base  of  the  neck ; 
while,  in  the  use  of  other  varieties,  the  superincumbent  pressure 
is  still  received  by  the  extremity  of  the  neck,  increasing  rather 
than  diminishing  its  curvature.  The  cause  of  flexion,  namely, 
the  weight  of  the  viscera  received  on  the  cervix,  must  be  removed 
as  formerly  shown,  to  insure  a  radical  relief.  The  bad  conse- 
quences of  flexion,  especially  as  producing  dysmenorrhoea,  steri- 
lity, etc.,  are  so  serious,  that  this  idea  should  never  be  forgotten. 
If  the  uterus  therefore  be  restored  by  means  of  a  lever  or  other 
variety  of  a  ring  pessary,  and  an  uterine  sound  be  occasionally 
passed,  say  once  or  twice  a  week,  into  the  cavity  of  the  uterus, 
thus  straightening  the  neck,  the  curvature  will  gradually  dis- 
appear, and  often  dysmenorrhoea  or  sterility  will  vanish.  Cer- 
tainly, this  measure  should  be  faithfully  tried  for  a  long  time, 
before  resort  be  had  to  the  intra-uterine  stem,  to  the  uterotome, 
or  to  the  elaborate  operation,  proposed  by  Dr.  Emmet,  of  New 


RETROVERSION.  437 

York,  demanding  much  dexterity,  involving  great  danger  from 
hemorrhage  and  inflammation,  a  tedious  confinement,  resulting  in 
more  or  less  deformity  of  the  cervix,  and,  we  must  imagine,  with 
uncertain  benefit. 

Eetroversioist. — In  retroversion  and  retroflexion  of  the  uterus, 
all  the  usual  pessaries  fail  in  maintaining  the  fundus  in  situ,  even 
when  assisted  by  stems  passing  out  of  the  vagina ;  indeed,  they 
not  merely  fail,  but  are  decidedly  injurious.  The  intra-uterine 
and  lever  pessaries,  however,  well  fulfil  the  important  indication 
of  restoring  the  axis  of  the  uterus  to  its  parallelism  with  that 
of  the  superior  strait,  and  of  maintaining  this  position  under 
all  the  motions  of  the  patient.  Their  advantages  and  disadvan- 
tages, the  beneficial  effects  and  the  difficulties  and  dangers  which 
may  result  from  resorting  to  the  one  or  to  the  other  form  pro- 
posed, have  been  so  fully  detailed,  with,  we  hope,  candor  and  love 
of  truth,  that  the  question  of  their  relative  importance  must  now 
be  left  to  the  judgment  and  experience  of  others.  If  both  should 
fall  short  of  public  expectation,  doubtless  the  ingenuity  and 
science  of  others  will  substitute  something  more  safe  and  prac- 
tical, to  support  the  uterus  in  its  proper  position  without  exciting 
nervous  or  organic  irritation,  and  thus  relieve  its  local  and 
functional  disturbances,  with  the  distressing  and  horrible  influ- 
ences of  cerebro- spinal  irritations,  involving,  as  they  do,  the  whole 
corporeal,  intellectual,  and  spiritual  being.^ 

1  This  subject  of  retroversion  of  the  uterus  has  greatly  engrossed  professional 
attention  since  the  time  of  Dr.  William  Hunter  ;  first,  as  it  existed  in  the  pregnant 
condition,  and  second,  in  the  unimpregnated  state.  It  seems  wonderful,  at  the 
present  day,  that  very  little  advance  has  been  made  towards  unity  in  sentiment 
and  especially  towards  uniformity  in  practice.  A  very  large  proportion  of  modern 
observers  are  disposed  to  consider  the  fact  of  retroversion  as  of  minor  importance, 
attributing  the  alleged  symptoms  to  complications.  Most  practitioners  affirm  that 
partial  inflammations,  or  congestions,  or  tumors  in  the  posterior  part  of  the  uterus 
are  the  real  cause  of  the  accident  ;  and  these  being  removed,  the  displacement  will 
disappear,  or  be  innocuous.  Hence,  antiphlogistic  remedies  are  much  trusted 
to,  or,  if  the  cause  cannot  be  removed,  the  displacement  with  all  its  attendant  evils 
is  deemed  intractable.  Few  put  confidence  in  pessaries,  dreading  bad  influences, 
or  cautiously  employ  them  as  palliatives.  Sir  James  Y.  Simpson  still  has  confi- 
dence in  the  intra-uterine  stem,  but  most  good  authorities,  perhaps  all,  condemn 
it  as  dangerous. 

Our  own  views  are  so  diametrically  opposed,  both  thoeretieally  and  practically, 
to  the  above  sentiments,  and  they  have  been  so  sustained  by  our  clinical  expe- 
rience, that  we  cannot  but  hope  that  much  may  be  achieved  by  others  in  relieving 


438      TREATMENT    OF    VARIETIES    OF    DISPLACEMENTS. 

The  following  account,  as  drawn  up  by  a  former  patient,  has 
been  received  since  the  preceding  pages  have  been  in  type.  It 
is  interesting  as  presenting  some  very  peculiar  and  singular  phe- 
nomena, developed  first  during  pregnancy,  continued  after  deli- 
very in  connection  with  a  retroverted  uterus,  and  disappeared 
when  this  displacement  was  relieved.  The  patient  now  no  longer 
wears  a  support,  and  is  entirely  free  from  pelvic  and  uterine  irri- 
tation. 

Case. — "  About  two  months  previous  to  the  birth  of  my  fifth 
child,  while  walking  across  the  room,  I  was  suddenly  checked  in 
my  progress  by  the  seeming  dislocation  of  (the  pubic)  bones, 
which  in  my  ignorance  of  anatomy  I  believed  to  be  jointed, 
causing  intense  agony,  accompanied  with  a  sound  like  a  pistol- 
shot  :  leaning  on  something  near  by,  for  support,  the  movement 
of  the  body  caused  the  bone  to  slip  in  place  again,  when  I  was 
enabled  to  take  a  few  steps,  with  great  suffering,  as  the  soreness 
and  stiffness  were  almost  unendurable.  Such  painful  sensations 
and  sounds  recurred  over  and  over,  when  attempting  to  get  up 
or  lie  down,  to  the  birth  of  a  fine  large  child,  which  it  may  be 
proper  to  state  caused  less  pain  (though  quite  enough)  than  I  had 
ever  experienced  on  any  previous  occasion — leaving  me,  how- 
ever, with  prolapsus  of  the  womb,  and  all  the  miserable  feelings 
incident  to  such  diseases,  until  eighteen  months  after,  when, 
finding  I  was  to  become  a  mother  again ;  then  my  health  ap- 
peared almost  restored,  up  to  the  two  or  three  last  months  before 
confinement,  when  I  suffered  exactly  as  before  mentioned — which, 
contrary  to  expectation,  brought  no  relief — my  troubles  were 
steadily  increasing.  The  pain  in  the  bones  seemed  permanent ; 
numbness  and  stiffness  in  the  left  hip,  which  also  gave  way  with 
a  noise,  and  pain  when  I  would  lift  my  foot.  Then  I  learnt  to 
drag  it,  as  if  paralyzed.  This  continued  for  six  months,  when  I 
was  taken   to   Philadelphia,  where  I  was   speedily  relieved  of 

retroversion  of  the  uterus,  and  that  the  profession  will  regard  it,  in  most  instances, 
as  the  cause  and  not  the  consequence  of  morbid  complications.  We  trust  also  that 
the  idea  will  be  received,  that  flexions  in  general,  and  hence,  also,  retroflexion,  are 
but  the  result  of  pressure.  Hence,  the  pressure  being  removed  from  the  cervix, 
and  the  body  of  the  uterus  being  reinstated  in  its  natural  position  ;  the  severe  and 
dangerous  operations  of  the  bilateral  section  of  the  canal  of  the  cervix,  the  slit- 
ting up  its  sides  by  scissors,  the  dividing  the  neck  posteriorly,  the  amputating 
one  of  the  lips  or  the  whole  cylinder  of  the  cervix  now  so  rife,  will,  if  not  entirely 
abandoned,  be  at  least  restricted  to  some  few  extraordinary  cases. 


PROCIDENTIA.  439 

mucli  tliat  had  distressed  me,  thougli  four  montlis  elapsed  before 
I  was  sensible  of  a  decided  improvement  in  the  aching  bones.  I 
continued  to  wear  an  internal  support,  for  several  years ;  believing 
it  to  be  the  first  cause  of  relief.  I  had  a  morbid  fear  that  with- 
out it  I  should  relapse  into  mj  former  wretched  condition ;  such, 
however,  has  not  been  the  case,  as,  save  for  bronchial  difficulties 
(which  is  foreign  to  our  subject),  I  might  be  pronounced  well. 
And  filled  with  gratitude,"  etc.  etc. 

Procidentia. — In  procidentia  uteris  the  great  relaxation  of  the 
vagina  and  perineum  is  almost  universally  a  complication  de- 
manding special  attention.  When  this  complication  is  absent,  no 
special  difficulty  exists  in  most  cases ;  for,  the  uterus  being  by  a 
little  pressure  returned  into  the  pelvis,  is  found,  as  formerly 
demonstrated,  in  a  state  of  retroversion,  and  should  be  treated, 
therefore,  for  reasons  frequently  stated,  by  the  "  lever  pessary." 
ISTevertheless,  since  the  vagina  is  usually  much  relaxed  and  dis- 
tended, and  also  since  procidentia  occurs  most  frequently  in 
elderly  females,  past  the  change  of  life,  when  the  uterus  has 
often  dwindled  in  size,  and  is  comparatively  free  from  irritation ; 
several  of  the  varieties  of  pessaries  above  enumerated  will  prove 
useful.  The  author  has  therefore  succeeded,  with  the  flat  ring, 
especially  when  the  circumference  of  the  ring  has  been  compara- 
tively thick,  and  also  with  a  large  disk  pessary,  the  plano-convex 
and  the  double  convex  pessary. 

In  cases  of  procidentia  uteri  with  great  relaxation  of  the 
vagina,  the  disk  or  the  convex  pessaries  are  often  demanded  to 
support  the  vagina  within  the  vulva;  for  with  the  lever  or 
other  varieties  of  the  ring  pessary  the  coats  of  the  vagina  fall 
over  the  margin  or  through  the  opening  of  the  instrument,  and 
may  protrude  from  the  vulva  sufficiently  to  annoy  the  patient. 
In  such  cases,  when  the  disk  or  convex  pessary  is  employed, 
more  than  ordinary  attention  will  be  demanded  to  prevent  the 
accumulation  of  fluids,  and  an  increase  of  leucorrhoeal  discharges, 
fetid  excretions,  etc.  Occasionally  the  instrument  riiust  be  re- 
moved for  a  few  days,  and  astringent  washes  employed  to  the 
vagina,  while  the  patient  is  kept  in  bed  until  the  discharges  have 
ceased  and  the  instrument  been  cleansed. 

The  modus  operandi  of  pessaries  in  great  relaxation  of  the 
vagina  is  first  to  carry  the  whole  tube  completely  within  the 


440      TREATMENT    OF    VARIETIES    OF    DISPLACEMENTS. 

bones  of  the  pelvis.  Hence,  a  large  size  is  generally  requisite. 
If  the  lever  be  used,  the  suggestion  of  Dr.  Churchill  of  an  addi- 
tional bar  on  the  lower  portion  of  the  instrument  will  be  benefi- 
cial. This  pessary  also  should  be  as  long  and  as  much  curved  as 
suits  the  comfort  of  the  patient,  so  as  to  carry  the  upper  part  of 
the  vagina  as  high  as  possible  behind  the  uterus.  A  second 
advantage  of  the  pessary  is,  by  its  pressure,  to  stimulate  the 
muscular  and  organic  actions  of  the  coats  of  the  vagina,  so  as  to 
facilitate  its  contraction,  or  as  Dr.  Sharpless  would  express  it,  to 
increase  its  tonicity  and  condensation.  Third,  this  pressure  may 
be  sometimes  so  great  as  to  excite  a  moderate  degree  of  vaginitis; 
hence,  as  above  intimated,  increasing  the  mucoid  and  seroid  dis- 
charges. Such  inflammation,  if  moderate,  serves  still  more  to 
condense  and  thicken  the  coats  of  the  vagina,  so  that  a  smaller 
pessary  will  be  required.  Of  course,  the  effect  of  the  instrument 
must  be  watched  that  no  severe  inflammation  or  ulceration  be 
excited ;  in  which  case  it  should  be  removed  and  the  patient 
kept  at  rest  under  the  free  use  of  emollient  and  astringent  washes, 
until  the  parts  will  again  tolerate  a  support.  In  this  way,  a  per- 
fect cure  may  be  occasionally  anticipated;  and  although  the 
treatment  is  tedious,  yet,  during  the  whole  time,  the  patient  can 
be  allowed  to  move  about,  and  attend  to  her  ordinary  labors, 
with  little  or  no  discomfort.  The  plan  is  simple,  efficient,  and 
void  of  danger,  and  should,  we  think,  be  tried  by  those  who 
abandon  such  cases  as  intractable,  or  resort  to  perineorrhaphy  or 
elytrorrhaphy,  accompanied,  as  these  operations  are,  with  many 
difficulties  and  dangers. 


DISPLACEMENTS  OF  THE  VAGINA,  etc. 

Prolapsus  of  the  Vagina,  etc. — There  are  cases  oi prolapsus 
of  the  vagina^  described  by  authors  as  distinct  and  independent  of 
displacements  of  the  womb ;  but  practically  they  require  no  dif- 
ferent treatment  from  procidentia  uteri  with  relaxed  vagina,  and 
they  are  seldom  disconnected  from  some  degree  of  prolapsus  or 
retroversion  of  the  uterus. 

These  cases  of  prolapsus  of  the  vagina  are  often  designated  as 
cases  of  cystocele,  or  reciocele,  or  "  hernia  of  the  bladder  or  rectum  ;" 
because  in  bad  cases  the  bladder  or  rectum,  as  they  are  closely 


CYSTOCELE — RECTOCELE.  441 

adherent  to  the  walls  of  the  vagina,  will  descend  and  protrude 
externally. 

If  it  be  a  cystocele,  mere  tactile  examination,  when  the  bladder 
is  empty,  will  not  usually  detect  this  complication ;  but  by  care 
it  will  be  found  that  there  is  a  greater  prominence  than  is  natural 
at  the  anterior  portion  of  the  orifice  of  the  vagina,  that  there  is 
an  increase  of  this  swelling  when  the  urine  has  been  retained  for 
some  hours,  that  there  is  evident  fluctuation,  and  sometimes  ten- 
sion, and  that  there  is  a  sudden  disappearance  of  these  symptoms 
after  micturition.  The  diagnosis  is  confirmed  by  passing  a  ute- 
rine sound,  or  a  curved  catheter,  with  its  convexity  towards  the 
pubis,  into  the  bladder,  when  the  point  will  easily  be  felt  through 
the  parietes  of  the  tumor  outside  of  the  vulva.  The  patient  com- 
plains of  sensations  of  fulness,  pressure,  and  weight,  especially 
when  the  urine  accumulates,  or  when  she  stands  or  walks ;  and 
local  irritations  from  exposure,  sometimes  amounting  to  inflam- 
mation, not  unfrequently  occur.  There  is  generally  frequent 
inclination  to  micturate,  to  dysuria,  and  sometimes  inability  to 
empty  the  bladder  until  by  pressure  the  tumor  is  reinstated. 

In  other  instances,  which  are  comparatively  rare,  the  posterior 
wall  of  the  vagina  is  more  relaxed,  and  protrudes,  bringing"  with 
it  the  anterior  wall  of  the  rectum,  thus  constituting  a  rectocele.  If 
this  should  be  suspected,  its  existence  may  be  confirmed  very 
readily,  by  passing  a  finger  into  the  rectum,  and  curving  it  for- 
wards, when  it  is  readily  perceived  outside  of  the  vulva,  covered 
by  the  combined  coats  of  the  vagina  and  rectum.  In  addition 
to  the  usual  symptoms  of  fulness,  weight,  etc.,  in  such  cases, 
there  is  apt  to  be  tenesmus,  distension  of  the  pouch  from  gas, 
fluids,  and  sometimes  solid  faeces,  on  the  evacuation  of  which  the 
tumor  collapses. 

In  one  case  that  we  recall,  cystocele  and  rectocele  both  existed 
in  the  same  patient,  and  were  readily  detected  by  the  catheter  in 
the  bladder  and  the  finger  in  the  rectum. 

The  treatment  in  all  such  cases  is  comparatively  very  easy. 
Empty  the  bladder  and  the  rectum,  and  then  introduce  a  large 
disk  or  convex  pessary  into  the  vagina,  so  as  to  render  it  suffi- 
ciently tense.  By  this  means,  the  symptoms  will  be  immediately 
relieved.  Astringent  washes  must  be  daily  employed.  After  a 
few  weeks  or  months  from  the  combined  influence  of  the  astrin- 
gents, and  the  pressure  of  the  pessary,  such  condensation  of  the 


442      TREATMENT    OF    VARIETIES    OF    DISPLACEMENTS. 

tissues  may  be  expected,  that  a  smaller  pessary  will  answer,  and 
subsequently  tbe  support  may  be  entirely  pretermitted. 

In  the  use  of  the  pessary,  attention  should  always  be  paid  to 
the  condition  and  position  of  the  uterus,  so  that  its  displacement 
may  be  relieved  as  well  as  that  of  the  vagina.  From  our  own 
experience,  we  cannot  conceive  of  any  cases  in  which  such  treat- 
ment should  be  so  ineffectual  as  to  j  ustify  an  attempt  to  diminish 
the  size  of  the  vulva,  or  the  vulvo-uterine  canal,  by  resort  to  the 
knife,  or  perhaps  the  more  dangerous  employment  of  caustics.^ 


HERNIA  OF  THE  BLADDER. 

Although  the  above  mentioned  cases  of  protrusion  of  the  blad- 
der or  the  rectum  are  usually  termed  hernia^  yet  strictly  this 
name  is  not  applicable  to  them,  as  there  is  no  opening  or  foramen 
through  which  either  viscus  has  been  forced,  but  there  is  simply 
great  yielding  of  the  coats  of  the  bladder  or  rectum  and  the 
vagina.  Hence  there  is  no  danger  of  inflammation  or  strangula- 
tion as  in  inguinal  or  crural  hernia,  whether  the  intestines  or 
bladder  protrude. 

Case. — The  following  history  of  a  unique  variety  of  hernia  of 
the  bladder  to  which  the  name  more  strictly  belongs,  may  not 
prove  uninteresting.  Many  years  ago,  an  unmarried  lady  very 
imprudently  attempted  to  raise  a  heavy  weight.  She  felt  imme- 
diately that  something  had  given  way  internally.  She  com- 
plained of  a  weakness,  a  feeling  of  protrusion  at  the  vulva,  as  if 
something  must  escape  if  she  continued  in  the  erect  posture. 
Soon  afterwards,  she  recognized  a  decided  swelling  at  the  orifice 
of  the  vagina.  No  professional  examination  of  the  part  was 
allowed.  She  was  requested  to  remain  continually  in  bed,  and 
persevere  in  the  use  of  cold  and  astringent  washes,  with  suitable 
attention  to  her  bowels. 

Some  months  expired  and  no  permanent  benefit  resulted ;  the 
patient  was  perfectly  well  in  the  recumbent  position,  but  uncom- 
fortable when  erect.  An  examination  was  now  permitted,  and  a 
slight  prolapsus  of  the  uterus  was  detected,  with  such  a  degree  of 
apparent  relaxation  of  the  anterior  wall  of  the  vagina  as  to  allow 

'  See  note  on  page  376. 


HERNIA    OF    THE    BLADDER.  443 

a  vaginal,  but  not  a  uterine  protrusion  at  tlie  vulva.  A  pessary 
was  employed  with  trifling  relief;  its  sliape  and  size  were  vari- 
ously modified,  but  still,  tlie  fulness  at  the  vulva  continued  trou- 
blesome. This  was,  of  course,  very  surprising  in  a  virgin,  the 
tissues  being  tense,  and  the  hymen  existing.  A  more  careful 
investigation  was  now  instituted.  The  uterus  had  been  sufficiently 
elevated  by  the  pessaries,  but  it  was  found  that  a  portion  only  of 
the  vagina  was  relaxed ;  this  was  situated  not  on  the  anterior, 
but  on  the  right  and  lower  portion  within  the  rami  of  the  pubis 
and  ischium.  When  the  swelling  was  reduced,  a  longitudinal 
opening  could  be  recognized  by  the  finger,  apparently  in  the 
pelvic  fascia.  The  point  of  a  curved  catheter  passed  into  the 
bladder  could  be  felt  in  the  vaginal  tumor,  coming  through  this 
lateral  opening.  Here,  indeed,  was  detected  a  regular  cystic 
vaginal  hernia,  penetrating  between  separated  fibres  of  the  pelvic 
fascia  near  the  foramen  thyroideum,  and  on  the  inner  surface  of 
the  levator  ani  muscle  of  the  right  side.  The  whole  was  reducible 
by  steady  pressure  with  the  finger,  but  partially  returned  as  soon 
as  this  was  intermitted ;  and  the  tumor  reappeared  at  the  orifice 
of  the  vagina  as  soon  as  the  patient  stood  erect.  No  other  portion 
of  the  vagina  was  implicated.  The  nature  of  the  case,  and  the 
indications  to  be  fulfilled,  were  now  evident ;  but  the  means  at 
command  proved  very  inefficient.  Innumerable  varieties  of  pes- 
saries, with  and  without  springs,  were  tried,  but  the  tumor  would 
press  around  or  over  them ;  no  firm,  unyielding  pressure  could  be 
made  on  the  opening,  so  as  to  prevent  the  egress  of  the  bladder. 
Success,  however,  eventually  was  gained  by  means  of  what  might 
be  termed  a  T  pessary,  that  is,  a  large  cylinder,  about  the  length 
of  the  vagina,  to  the  middle  of  which  a  smaller  cylinder  was 
attached  at  right  angles.  This  was  introduced  and  so  arranged, 
that  the  large  cylinder  extended  from  the  foramen  thyroideum  to 
the  upper  part  of  the  vagina,  which  space  it  completely  occupied ; 
the  small  cylinder  was  then  placed  across  the  vagina,  its  ex- 
tremity pressing  against  the  left  side,  so  as  to  keep  the  larger  or 
longitudinal  portion  so  firmly  in  position,  under  all  the  varying 
motions  of  the  patient,  that  the  hernia  did  not  escape.  The 
instrument  was  worn  for  many  months,  without  any  special 
trouble,  and  was  then  removed.  Some  twenty-five  years  have 
since  elapsed ;  the  lady  is  still  living,  at  an  advanced  age,  but 
without  having  had  any  return  of  this  old  enemy. 


4-44      TREATMENT    OF    VARIETIES    OF    DISPLACEMENTS. 

STRENGTHENING  THE  NATURAL  SUPPORTS. 

l!:\iQ  fourth  indication  in  the  treatment  of  displacements  of  the 
uterus  is  so  to  strengthen  the  natural  supports  of  the  uterus  that 
artificial  assistance  may  no  longer  be  required.  Our  means  are 
here,  however,  very  limited.  We  must  trust  merely  to  the  usual 
recuperative  powers  of  nature. 

Those  who  imagine  that  the  uterus  is  supported  merely  by  the 
tonicity  and  contraction  of  the  vagina  depend,  of  course,  upon 
astringents,  tonics,  and  cold  applications  to  this  canal ;  and,  these 
failing,  they  have  been  bold  enough  to  resort  to  surgical  opera- 
tions to  diminish  mechanically  the  size  of  the  vagina,  or,  it  may 
be,  of  the  vulva,  for  a  radical  cure.  We  have  already  noticed 
the  falsity  of  the  theory  on  which  this  practice  is  founded,  and 
its  inefficiency,  except,  perhaps,  in  some  cases  of  procidentia  uteri. 

When  displacements  of  the  uterus  arise  from  increased  weight 
or  size  of  the  organ,  or  from  increased  pressure  from  above — the 
natural  supports  remaining  good,  or  biit  slightly  impaired — then, 
if  such  increased  size,  weight,  or  pressure  can  by  any  means  be 
obviated,  the  ligaments  may  resume  their  duties,  and  the  organ 
be  supported  by  them  without  artificial  assistance.  This  is  often 
observed  in  cases  of  hypertrophy  from  pregnancy,  from  polypous 
tumors,  from  fluid  collections  in  the  cavity  of  the  uterus,  or  even 
from  simple  irritable  uterus;  the  causes  disappearing,  the  size  of 
the  uterus  diminishes,  and  the  ligaments  will  then  be  adequate 
for  the  sustentation  of  the  organ.  The  same  favorable  results 
may  be  anticipated,  in  some  cases,  when  constipation,  tympanites, 
ascites,  or  other  temporary  sources  of  pressure,  such  as  tight 
dresses,  braces,  etc.,  have  vanished.  In  most  instances,  however, 
there  is  such  an  elongation,  want  of  tonicity,  or  relaxation  of  the 
ligaments,  either  prior  to  or  after  the  displacement,  that  they  are 
inadequate  to  retain  the  womb  in  situ.  However  frequently  the 
organ  may  be  artificially  elevated,  it  again  falls  under  the  weight 
of  the  intestines  and  the  contraction  of  the  abdominal  muscles. 

Artificial  supports  or  pessaries  are,  therefore,"  demanded  for  the 
restoration  and  maintenance  of  the  uterus.  These  means  will 
usually  prove  not  merely  palliative,  but  radical.  This  anticipa- 
tion is  founded  on  the  general  physiological  fact  that  there  is  a 
natural  disposition  of  all  the  tissues  of  the  body,  especially  of 


CONTRACTION    OF    THE    LIGAMENTS.  4J:5 

the  muscular,  to  contract,  when  there  is  no  counteracting  cause. 
The  skin  and  areolar  tissue  are  continually  accommodating  them- 
selves to  the  size  of  the  subjacent  tissues ;  the  heart,  stomach, 
bowels,  bladder,  uterus,  etc.,  to  the  size  of  their  contents.  If  a 
limb  be  kept  uniformly  in  one  position  for  a  sufficient  length  of 
time,  the  muscles,  ligaments,  and  other  tissues  will  contract  so  as 
to  render  it  inflexible  and  useless. 

When  the  uterus  is  fully  supported  by  a  pessary,  and  especially 
if  the  fundus  be  tilted  well  towards  the  pubis,  all  the  ligaments 
previously  elongated  and  atonic  are  thrown  into  folds;  and  the 
organ  being  constantly  sustained  in  the  above  position,  there  exists 
no  counteracting  influence  to  prevent  the  shortening  of  the  liga- 
ments. Their  contraction  may  therefore  be  always  expected  after 
a  longer  or  shorter  period.  The  time  for  its  full  accomplishment 
must  exceedingly  vary,  according  to  the  vigor  of  the  patient, 
whether  she  has  never  been  pregnant  or  been  frequently  a  mo- 
ther, according  to  the  degree  of  elongation  and  atony  of  the  liga- 
ments, the  size  of  the  womb,  the  degree  of  pressure  from  the 
viscera,  etc. 

No  definite  time  can,  therefore,  be  fixed  at  which  a  patient  can 
dispense  with  an  artificial  support  after  there  has  been  a  chronic 
displacement,  especially  a  retroversion,  where  the  ligaments  are 
always  elongated.  We  have  removed  a  pessary  even  after  three 
months,  and  our  patient  has  remained  well ;  others  have  worn 
them  for  years,  and  yet  do  not  feel  comfortable  without  the  sup- 
port. Our  general  rule  is,  that  at  the  end  of  a  year  the  instru- 
ment may  be  removed  ;  but  if  symptoms  reappear,  and  especially 
if,  on  successive  examinations,  the  uterus  is  found  gradually  re- 
turning to  its  mal-position,  then  to  replace  the  pessary.  The 
inconvenience  of  wearing  a  support  is  trifling,  as  it  should  cause 
no  pain  or  irritation ;  and  the  miserable  consequences  of  displace- 
ment are  so  great,  that  the  propriety  of  continuing  its  use  can 
hardly  be  doubted. 

Of  course,  particular  circumstances  interfere  with  the  execution 
of  this  general  rule — as,  general  or  local  diseases  from  accidental 
causes,  but  especially  the  occurrence  of  pregnancy.  In  this  last 
case,  the  pessary  will  continue,  for  a  time,  to  be  useful,  as  has 
been  maintained,  in  preventing  any  displacement  in  the  early 
stages,  and  in  diminishing  any  predisposition  to  abortion.  After 
the  third  or  fourth  month  it  can  do  no  good,  as  the  uterus  becomes 


446      TREATMENT    OF    VARIETIES    OF    DISPLACEMENTS. 

SO  large  as  to  rise  out  of  the  pelvis,  and  it  might  be  injurious, 
from  the  enlarged  size  of  the  organ,  to  which  it  is  not  adapted. 

This  natural  disposition  of  the  ligaments  to  contract  is  our 
chief  reliance ;  but,  as  they  are  muscular  tissues,  we  may  conclude 
that  all  those  hygienic  and  medicinal  measures  which  increase  the 
tone  and  energy  of  the  general  muscular  system  will  greatly  assist 
recovery,  by  imparting  activity  and  strength  to  these  hitherto 
atonic  and  relaxed  ligaments.  Even  the  injections  of  cold  water, 
astringents,  and  tonics  into  the  vagina  may  have  a  sympathetic 
tonic  influence  on  these  supports.  As,  however,  the  ligaments 
are  internal,  among  the  intestines,  no  one  but  the  empiric  would 
speak  of  making  direct  applications  to  these  tissues  to  strengthen 
them. 


FLEXION  OF  THE  NECK  OF  THE  UTERUS. 


447 


CHAPTER    VIII. 

TREATMENT    OF    COMPLICATIONS    OF    DISPLACEMENTS 
OF    THE    UTERUS. 

Many  allusions  have  been  made  to  tlie  complications  of  the 
usual  forms  of  displacement,  the  treatment  of  which  has  now  been 
presented. 

FLEXION. 

With  prolapsus,  anteversion,  or  retroversion,  flexions  of  the 
neck  of  the  uterus  demand  very  little  special  treatment.  The 
passage  of  a  uterine  probe  two  or  three  times,  with  the  use  of  a 
ring  pessary,  is  almost  always  successful.  The  annexed  drawing 
of  the  uterine  sound  or  probe  represents  that  degree  of  curvature, 
required  when  the  uterus  is  in  situ.     The  influence  of  the  probe 


IS  temporary,  that  of  the  ring  permanent ;  the  latter  transfers  the 
superincumbent  pressure,  which  is  the  cause  of  the  flexion,  from 
the  extremity  of  the  cervix  to  the  body  of  the  uterus,  at  its  junc- 
tion with  the  neck.  The  vagina  attached  to  the  lower  extremity 
of  the  neck,  is  stretched  out  by  the  pessary,  like  a  tent,  and 
receives  also  part  of  the  pressure  ;  so  that,  the  balance  being  borne, 
as  just  mentioned,  by  the  lower  part  of  the  body  of  the  womb,  the 
neck  is  entirely  liberated.     The  cause  of  flexion  is  no  longer 


448      TREATMENT — COMPLICATIONS    OF    DISPLACEMENTS. 

operative,  and  this  complication,  so  fruitful  of  functional  uterine 
distress,  disappears.^ 

The  ring  not  only  delivers  the  cervix  from  this  complication, 
but,  preventing  all  firm  contact  with  the  posterior  portion  of  the 
vagina,  it  liberates  the  extremity  of  the  neck  from  that  attrition 
which  so  often  induces  and  keeps  up  inflammatory  affections  of 
the  OS  uteri.  Hence,  not  only  are  dysmenorrhoea  and  sterility 
frequently  obviated  by  the  ring,  as  formerly  mentioned,  but  it 
becomes  also  an  important,  if  not  an  essential,  adjuvant  in  the 
treatment  of  inflammations  of  the  cervix. 


MENSTRUAL  DISTURBANCE. 

Frequent  notice  has  already  been  given  of  the  great  benefit  to 
be  experienced  from  a  proper  support  to  the  uterus,  in  cases  of 
displacements  complicated  with  leucorrhcea,  menorrhaijia,  and  even 
hemorrhages  from  the  uterus.  By  relieving  the  irritation  from  the 
displacement,  they  usually  prevent  the  congestion  of  the  uterine, 
vessels,  which  is  the  cause  of  such  discharges.  Hence  leucorrhcea 
and  monorrhagia,  which  have,  from  time  immemorial,  been  so 
indomitable  as  to  be  ranked  among  the  "opprobria  medicorum," 
will,  often,  by  these  means,  become  very  manageable.  They 
should  no  longer  be  regarded  as  "  weaknesses,"  but  as  the  results  of 
irritation ;  and  let  it  be  remarked,  also,  that,  in  a  large  majority  of 
cases,  these  vaginal  evacuations  of  mucus,  serum,  menses,  and 
blood,  are  the  sequeloe  not  of  inflammatory  or  organic,  but  of 
nervous  irritation.  Hence  in  such  cases  the  use  of  leeches,  cups, 
and  blisters,  of  astringent  and  stimulating  washes,  and  the  employ- 
ment of  nitrate  of  silver,  of  caustic  potash,  of  the  acid  nitrate  of 
mercury,  and  other  analogous  measures,  will  not  reach  the  root 
of  the  evil.  The  congestion  may  be  relieved  for  the  time,  but  it 
will  certainly  return,  even  when,  as  we  have  often  known,  this- 
course  of  practice  had  been  pursued  for  many  years.  On  the 
contrary,  if  the  nervous  irritation  of  the  uterus  be  relieved,  the 
congestion  will  disappear  and  not  return,  no  matter  whether  such 
irritations  arise  from  displacements  of  the  uterus,  or  from  sym- 
pathy with  the  bladder,  the  rectum,  the  stomach,  or  the  cerebro- 

■   Vide  Treatment  of  Anteversion  with  Flexion,  p.  436. 


HYPERTROPHY.  449 

spinal  centres.  If  there  be  no  irritation,  there  is  no  congestion, 
and  if  there  he  no  congestion,  there  will  be  no  preternatural 
evacuations.  Thus  the  uterus,  free  from  irritation,  resumes  its 
normal  functions. 


ENLARGEMENTS  AND  TUMORS  OF  THE  UTERUS. 

Hypertrophy.  —  Displacements  are  also  complicated  with 
hypertrophy  of  the  uterus,  a  natural  growth  of  tissue  without 
disorganization.  Many  such  cases  are  met  with,  where  there  are 
no  tumors,  or  other  permanent  sources  of  irritation. 

The  cause  may  be  often  traced  to  the  continued  state  of  irrita- 
tion and  engorgement,  kept  up  by  a  disiilaced  uterus.  Such  cases 
of  hypertrophy  are  too  often  treated,  and  certainly  with  doubtful 
success,  by  evacuants,  by  the  local  and  general  use  of  iodine,  or 
of  mercurials  carried  to  the  extent  even  of  salivation ;  by  the  use 
of  such  topical  remedies  as  astringents,  stimulants  in  the  form  of 
washes,  powders,  and  ointments;  by  scarifications,  incisions,  and 
leeches ;  and  by  caustics  of  every  variety.  If,  however,  the  dis- 
placement be  relieved,  especially  by  some  form  of  the  ring  pes- 
sary, the  irritation  is  removed ;  the  troublesome  and  distressing 
pains  and  nervous  symptoms  disappear,  and  the  congestion 
vanishes ;  there  is  no  increase  of  the  enlargement,  as  the  pabu- 
lum is  destroyed;  and,  gradually,  the  uterus  diminishes  by  the 
process  of  interstitial  absorption  to  its  natural  size,  precisely  as 
the  uterus  of  an  aged  female  shrivels,  after  the  normal  excite- 
ments of  her  menstrual  life  have  terminated.  Thus,  we  have 
often  known  hypertrophies  disappear,  and  females  who,  from 
this  cause,  have  been  sterile  for  years,  again  become  mothers. 

Moreover,  hypertrophies  of  course  are  often  dependent  upon 
polypi.  In  these  cases,  prolapsus  or  retroversion  may,  and  gene- 
rally does  exist,  from  the  increased  size  and  weight  of  the  organ, 
and  thus  aggravates  the  symptoms.  The  polypus  usually  can  be, 
and  of  course  ought  to  be,  removed.  Then,  the  irritation,  as  in 
other  cases,  being  relieved,  the  congestion  ceases,  and  the  uterus 
gradually  diminishes  to  its  normal  size,  and  may  thus  possibly 
regain  its  natural  position.  Should  this  however  not  be  the  case, 
the  usual  treatment  for  displacements  will  be  demanded.  In  a 
few  instances  of  intra-uterine  polypi  with  displacement,  the  poly- 
29 


450       TREATMENT — COMPLICATION'S    OF    DISPLACEMENTS. 

pus  cannot  be  immediately  removed,  from  occlusion  of  the  os 
uteri,  from  adhesions  of  the  tumor,  or  from  other  causes.  In 
such  cases,  more  or  less  palliation  may  be  given  to  the  symp- 
toms by  pessaries,  relieving  the  displacement;  but,  no  radical 
relief  can  of  course  be  effected,  so  long  as  the  polypus  remains. 

It  has  been  asserted  by  some  pathologists  that  apparent  dis- 
placements of  the  uterus  exist  where  the  body  is  in  its  natural 
position,  but  the  cervix  so  elongated  that  it  presses  upon  the  floor 
of  the  pelvis.  Others  regard  this  elongation  of  the  neck  as  a 
cause  of  displacements,  especially  of  procidentia  uteri;  still,  a 
large  number  consider  it  as  a  cause  often  of  dysmenorrhoea,  and  , 
more  frequently  of  sterility. 

This  elongation  is  sometimes  inappropriately  regarded  as  con- 
genital, but  certainly  should  be  considered  as  merely  an  inordi- 
nate development  of  the  cervix,  without  any  prior  irritation  or 
disease,  the  tissues  being  quite  natural.  It  should  be  termed 
spontaneous  or  natural  hypertrophy.  The  cervix  is  usually  de- 
scribed as  being  of  a  conical  form,  tapering  towards  the  os  ex- 
ternum, and  varying  from  two  inches  to,  it  is  said,  four  inches  in 
length.  Of  course,  it  must  sometimes  be  very  far  back,  presenting 
towards  the  sacrum,  qr  occasionally  forwards,  and  has  a  tendency 
to  appear,  or  even  to  protrude  at  the  os  externum  vaginae.  A 
more  frequent  cause  of  this  elongation  is  hypertrophy,  or  actual 
induration  of  the  cervix,  by  which  not  only  the  volume,  but  the 
length  of  the  neck  is  increased. 

In  all  such  cases,  symptoms  of  prolapsus,  usually  with  flexions, 
dysmenorrhoea,  sterility,  etc.  exist.  It  is  frequently  complicated 
with  the  various  displacements  of  the  uterus,  especially  retrover- 
sion. Practitioners  have  been  so  much  puzzled  in  the  manage- 
ment of  these  uterine  displacements,  especially  of  these  cases  of 
natural  or  accidental  hypertrophy  of  the  cervix,  that  the  ordinary 
measures  failing,  they  have  become  more  bold,  and  resorted  to 
amputation  of  the  cervix^  an  operation  which  has  always  been  con- 
sidered dangerous,  and  which  has  certainly,  even  in  the  most 
skilful  hands,  sometimes  proved  fatal.  It  has  been  often  employed 
in  cases  of  malignant  diseases  of  the  neck,  certainly  with  very  little 
success.  M.  Huguier,  of  Paris,  has,  of  late  years,  recommended  it 
in  cases  of  hypertrophy,  sometimes  dissecting  up  a  portion  of  the 
vaginal  mucous  membrane  from  the  cervix,  so  as  to  remove  a 
larger  portion  of  this  body.     Sir  James  Y.  Simpson,  Drs.  Tilt 


UTERINE    TUMORS.  451 

and  Aslawell,  in  Britain,  and  Drs.  J.  Marion  Sims,  Emmet,  and  F. 
Gaillard  Thomas,  of  New  York,  have  also  recommended  it. 

That  there  are  some  cases,  especial!  j  in  non-malignant  fungous 
growths  from  the  cervix,  or  in  decided  cases  of  natural  hyper- 
trophy where  this  operation  is  advisable,  may  be  admitted ;  but 
"we  can  hardly  conceive  it  possible  that  it  would  ever  be  neces- 
sary in  cases  of  acquired  hypertrophy ;  inasmuch  as  such  enlarge- 
ments may  be  gradually  dissipated,  and  their  present  inconveni- 
ences relieved  by  means  of  ring  pessaries.  This,  at  least,  is  the  con- 
stant result  of  our  experience.  We  must  consider,  also,  that  all 
such  operations  upon  morbid  tissues  must  be  hazardous.  As  for 
so-called  "  congenital"  or  natural  hypertrophy,  we  should  deem 
it  very  rare,  having  in  the  course  of  a  practice  of  half  a  century 
met  with  but  one  single  example. 

Respecting  the  mode  of  operation,  a  difference  among  prac- 
titioners exists ;  perhaps  the  knife  has  been  generally  preferred, 
and  Dr.  J.  Marion  Sims,  with  his  usual  dexterity,  has  dissected 
up  the  mucous  membrane  of  the  stump  of  each  lip,  so  as  to  draw 
it  as  a  flap  over  each  extremity  of  the  lips,  as  in  amputation  of 
the  extremities.  The  hemorrhage,  however,  primary  or  second- 
ary, has  been  generally  so  profuse  that  a  constant  tampon  has  to 
be  worn  for  a  week  or  ten  days  after  the  operation.  To  avoid 
this  difficulty,  the  "  serre-noeud"  or  the  "ecraseur"  has  been 
preferred. 

Tumors. — Enlargements  of  the  uterus  may  also  be  dependent 
on  mural  tumors,  and  then  almost  universally  produce  displace- 
ments. The  principles  have  already  in  these  essays  been  incul- 
cated, that  the  symptoms  of  pain  and  nervous  distress,  of  leucor- 
rhoeal  and  hemorrhagic  discharges,  which  so  often  attend  these 
cases,  are  referable,  not  entirely  to  the  presence  of  these  tumors, 
but  mainly  to  the  displacement,  caused  by  the  enlarged  size  and 
weight  of  the  organ;  that  the  bad  effects  arise,  therefore,  not 
directly,  but  indirectly,  from  these  heterologue  or  abnormal 
growths;  and  that  the  tumors  are  generally  quiescent,  not  active, 
often  existing  for  a  lifetime,  without  any  serious  or  troublesome 
symptoms,  if  there  be  no  displacement. 

Of  course,  there  are  many  exceptions,  as  these  tumors  may 
become  inflamed,  or  may  have  been  originally  scrofulous,  cancer- 
ous, or  otherwise  malignant.     These  are,  the  author  believes, 


452      TREATMENT — COMPLICATIONS    OF    DISPLACEMENTS, 

judging  from  his  own  experience,  very  generally  the  exceptions. 
So  many  instances  have  occurred  to  him,  of  uterine  tumors  with 
displacements,  leucorrhoea  and  menorrhagia,  and  the  consequent 
injury  of  the  patient's  general  health,  in  which,  by  simply  treat- 
ing the  displacement  by  pessaries,  all  the  local  symptoms  have 
been  dissipated ;  and  the  patients  have  so  often,  under  the  influ- 
ence of  fresh  air,  exercise,  tonics,  bathing,  etc.,  wonderfully  reco- 
vered, that  he  must  urge  upon  others  a  similar  practice  in  suitable 
cases,  founded  upon  the  often-repeated  principle,  of  removing  the 
local  irritations  due  to  the  displacement.  His  observation  now, 
for  a  long  series  of  years,  in  public  and  private  practice,  is 
directly  opposed  to  the  opinion,  that  those  abnormal  tumors  are 
often  either  originally,  or  secondarily,  of  a  malignant  character; 
or  that  they  are  often  subject  to  inflammatory  irritation. 

Although  post-mortem  examinations  occasionally  reveal  peri- 
tonitis, or  abscesses  connected  with  these  tumors,  yet  this  does 
not  invalidate  the  opinion  just  given;  for,  the  cases  are  innumer- 
able of  uterine  tumors  existing  for  many  years,  and  yet  not  affect- 
ing the  patient's  general  health,  or  at  least  not  producing  any 
serious  disease.  In  such  individuals,  death  generally  arises  from 
other  and  distinct  causes.  Cases  are  reported  of  death  merely 
from  the  enormous  size  of  the  masses,  so  great  as  to  interfere 
with  the  functions  of  the  thoracic  or  abdominal  viscera,  or  of  the 
arterial  or  venous  circulation.  Such  instances  are  still  less  fre- 
quently to  be  observed  than  those  which  terminate  by  inflamma- 
tion and  abscesses.  The  law  of  increment  is  not  yet  known,  or 
that  of  arrest  and  decrease.  There  can  be  no  doubt,  however, 
that  these  growths  often  remain  stationary  for  years,  that  some- 
times after  increasing,  even  rapidly  for  a  time,  their  development 
is  arrested  by  some  hidden  influences,  and  not  unfrequently  they 
diminish  and  disappear. 

The  following  case  will  be  interesting,  as  illustrating  the  facts 
stated,  and  the  principle  which  should  regulate  the  practice  which 
is  to  be  pursued. 

Case. — A  lady,  when  about  thirty -five  years  of  age,  was  mar- 
ried, believing  herself  in  perfect  health,  as  she  felt  quite  well  and 
was  not  conscious  of  any  unnatural  condition  of  her  organs.  Mar- 
riage revealed  a  complete  vaginal  obstruction.  Her  physician. 
Dr.  Marshall  Paul,  submitted  the  case  to  our  investigation  and 
subsequent  treatment.     We  found  the  whole  cavity  of  the  pelvis 


UTERINE    TUMORS.  453 

occupied  hj  a  very  hard  tumor,  situated  behind  the  vagina,  and 
in  front  of  the  rectum,  extending  from  the  orifice  of  the  vagina 
to  the  sacrum,  and  from  one  side  of  the  pelvis  to  the  other.  The 
impaction  was  so  complete,  that  the  tumor  was  nearly  in  contact 
with  the  fourchette  or  fr^enum  perinaei.  The  displaced  vagina  was 
turned  upwards,  and  behind  the  pubis  to  the  hypogastric  region, 
where  with  difficulty  the  os  uteri  could  be  touched  by  the  index 
finger  forced  upwards,  between  the  symphysis  pubis  and  the 
tumor.  Per  rectum,  a  regular  spherical  mass  was  recognized. 
The  urethra  was  drawn  up  behind  the  symphysis,  as  in  the  last 
stage  of  pregnancy.  By  a  hand  upon  the  abdomen  the  uterus 
could  be  detected  larger  than  natural,  and  the  whole  hypogastric 
and  iliac  regions  were  as  tumid  as  at  the  fifth  month  of  gestation. 
Irritability  had  gradually  increased,  and  was  manifested  chiefly 
by  inability  to  retain  her  urine  for  more  than  an  hour,  by  night 
or  day,  depriving  her  of  sleep,  of  the  comforts  of  social  inter- 
course, and  often  proving  very  distressing.  She  suffered  also 
from  constant  fatigue,  with  sensations  of  pressure  and  weight 
after  slight  exercise.     The  catamenia  were  regular. 

To  relieve  these  symptoms  the  indication  was  clear  to  elevate, 
if  practicable,  this  abnormal  mass  from  the  cavity  of  the  pelvis, 
and  to  keep  it  above  its  brim.  As  this  could  not  be  immediately 
accomplished  by  any  direct  pressure  with  the  fingers,  we  employed 
first  a  cylindrical  pessary  two  inches  in  length  and  half  an  inch 
in  diameter.  This  could  with  some  difficulty  be  introduced  into 
the  vagina,  so  as  to  lie  transversely  from«the  crus  of  one  ischium 
to  the  other,  and  close  to  the  perineum  in  front.  To  retain  it  in 
this  position,  a  short  stem  or  small  cylinder  was  attached  to  its 
centre,  and  allowed  to  project  at  the  vulva.  The  whole  instru- 
ment was  of  a  T  shape.  By  pressing  the  instrument  downwards 
and  backwards,  the  vagina  was  elongated  underneath  the  tumor. 
Soon  a  larger  cylinder  was  tolerated,  the  tumor  yielded  a  little ; 
by  the  gradual  introduction  of  larger  cylinders  or  balls,  and 
afterwards  by  the  use  of  more  than  one  at  a  time,  the  whole  mass 
was  elevated  above  the  superior  strait,  where  owing  to  its  great 
size  it  remained  supported.  Then  the  instruments  were  removed, 
and  the  patient  required  no  further  attention.  The  frequent  in- 
clination to  urinate  disappeared.  She  could  remain  in  bed  all 
night,  and  during  the  day  could  attend  to  her  social  duties.     Her 


45-1:      TREATMENT — COMPLICATIONS    OF    DISPLACEMENTS. 

health  was  good,  but  her  abdomen  was  greatly  enlarged,  as  if  at 
the  seventh  month  of  gestation. 

At  the  usual  period  of  life  her  menses  disappeared,  and  she 
then  reported  herself  as  becoming  smaller,  and  after  the  change 
was  established  the  diminution  was  marked.  On  asking  this  lady, 
now  about  fifty-five  years  of  age,  not  long  since,  respecting  her 
tumors,  she  exclaimed,  "  I  have  no  tumors,"  certainly  none  of 
which  she  is  conscious,  or  which  a  casual  observer  would  notice. 

This  and  various  other  cases  would  confirm  the  opinion  of  the 
innocuous  character  of  these  abnormal  growths  as  they  usually 
present  themselves ;  that  the  irritations  and  congestions,  with 
their  consequences,  leucorrhoea,  menorrhagia,  etc.,  often  existing, 
are  owing  to  the  weight  of  the  uterus  and  to  pressure  on  the 
bladder,  rectum,  or  nerves,  and  not  to  the  character  of  the  adven- 
titious growth;  that  such  pressure  being  relieved,  the  symptoms 
of  irritation  will  often  disappear  and  the  patient  enjoy  excellent 
health,  though  the  presence  of  the  tumors  continues ;  and  finally, 
that  there  is  strong  reason  to  believe  that  the  disposition  to  en- 
large will  eventually  lessen  and  entirely  cease,  and  that  in  some 
rare  cases  the  tumors  may  gradually  disappear.  The  diminution 
or  entire  relief  of  the  symptoms  by  means  of  pessaries  probably 
facilitates  this  tendency  to  spontaneous  arrest  and  disappearance, 
by  lessening  the  irritation  and  consequent  congestions,  while  it  is 
extremely  doubtful  whether  anything  can  be  accomplished  by 
medicinal  agents. 

Medicines,  in  these  cases,  are  of  no  further  use  than  to  main- 
tain the  healthfal  functions  of  the  organs  of  the  economy,  and 
to  impart  tone  to  the  system ;  as  resolvents,  they  are  not  to  be 
trusted. 

In  a  large  proportion  of  these  uterine  tumors  which  have 
occurred  in  our  practice,  the  enlargement  has  not  been  suffi- 
ciently great  to  retain  them  above  the  superior  strait  of  the  pelvis; 
so  that  the  continuance  of  pessaries,  even  for  years,  is  generally 
necessary.  Nevertheless,  the  irritations  from  the  displacement 
are  relieved  by  the  support  they  give  to  a  greater  or  less  degree ; 
indeed,  very  generally,  perfect  comfort  is  afforded  to  the  patient. 
The  form  given  to  the  pessary  must  vary  according  to  circum- 
stances, the  kind  or  degree  of  complication,  etc.;  but  generally 
the  "  lever,"  from  its  bent  form  accommodated  to  the  curve  of 
the  perineum  and  sacrum,  will  best  fulfil  the  indications.     But 


PESSARIES  —  COLPEURYNTERS.  455 

frequently,  however,  the  disk,  conical,  globe,  cylindrical,  or  other 
pessaries  may  be  very  important.  As  a  substitute  for  these 
instruments,  it  has  been  suggested  to  elevate  such  tumors  and 
enlargements  of  the  uterus  by  means  of  caoutchouc  bags  intro- 
duced into  the  vagina,  in  a  collapsed  state,  and  then  gradually 
distended  by  air  or  water,  as  the  sensations  of  the  patient  will 
allow.  These  colpeurynters,  as  they  have  been  called,  are  now 
much  employed,  and  doubtless  with  great  advantage,  in  many 
cases.  Care,  however,  should  be  taken  not  to  increase  the  irri- 
tations, and  the  sensations  of  weight  and  pressure  on  the  bladder, 
rectum,  perinaeum,  etc.,  and  also  that  a  right  direction  be  given 
to  their  pressure.  They  are  to  be  regarded  merely  as  temporary 
assistants,  from  the  perishable  character  of  the  material  employed. 
Hence,  if  any  constant  support  be  demanded,  the  pessaries  already 
recommended  must  be  resorted  to. 

The  important  practical  rule — avoid  pain  and  local  irritation 
from  the  pessaries — is,  of  course,  never  to  be  forgotten.  Much 
time  and  perseverance  are  often  demanded,  and  much  attention 
must  be  paid  to  avoid  pressure  on  prominent  or  sensitive  spots, 
by  altering  the  size,  form,  and  curvature  of  the  instrument,  es- 
pecially as  these  uterine  tumors  are  very  irregular  in  their  shape; 
and  sometimes  are  very  numerous,  and  situated  upon  different 
portions  of  the  uterus,  and  occasionally  render  the  organ  appa- 
rently immovable.  It  is  very  rarely,  however,  that  all  these  diffi- 
culties may  not  be  readily  overcome,  and  the  patient  be  relieved. 
Every  encouragement  may  be  presented  ;  that  the  support  being 
accomplished  without  pain  or  irritation,  the  symptoms  of  uterine 
trouble  will  entirely  disappear,  however  large  may  be  the  uterus 
and  its  parasitic  growths.  Like  warts  on  the  fingers,  or  sarcoma- 
tous or  fibrous  tumors  elsewhere  in  the  body,  they  may  be  tole- 
rated for  years,  if  the  bad  effects  of  pressure  or  other  irritations 
be  removed.  In  their  own  nature,  they  are  neither  painful  nor 
destructive. 

This  point  has  been  dwelt  upon  more  than  might  seem  to  be 
requisite,  but  this  general  principle  is  of  immense  importance,  as 
the  following  summary  of  facts  within  the  author's  cognizance 
will  prove, 

Antiphlogisiics. — In  a  great  number  of  cases  such  uterine  tumors 
have  been  treated  as  the  result  of  inflammation,  by  rest,  leeches, 
scarifications,  low  diet,  purgatives,  mercurial  cathartics,  and  ptyal- 


456       TREATMENT — COMPLICATIONS    OF    DISPLACEMENTS 

ism,  to  the  injury  and  sometimes  to  the  permanent  destruction  of 
the  general  health. 

Alteratives. — In  other  cases,  where  the  tumors  have  been  dis- 
tinctly recognized,  they  have  been  designated  as  scirrhous  and 
cancerous,  and  the  patient  been  abandoned  to  hopeless  misery 
with  the  continual  anticipation  of  a  dreadful  death;  or,  by  some 
enthusiastic  heroic  practitioner,  they  have  been  submitted  to 
repeated  salivations  and  to  the  most  powerful  narcotics,  etc.,  to 
arrest  the  progress  or  to  alter  the  nature  of  such  indurations. 
The  health  and  happiness  have  often  been  sacrificed  in  vain 
attempts  to  cure.  Many  such  patients  often  perish  by  the  still 
more  deleterious  efforts  of  empirics.  Occasionally  they  recover 
by  the  operation  of  natural  causes,  as  already  detailed,  to  the 
disgrace  of  the  profession  which  had  abandoned  the  case,  and  the 
exaltation  of  any  accidental  treatment  to  which,  at  the  time,  the 
patient  may  have  been  subjected. 

In  other  instances,  where  the  diagnosis  has  been  correctly  made, 
and  no  malignant  character  is  regarded  as  being  present,  still 
many  severe  remedies  are  continually  applied  to  ameliorate  the 
distress  and  pain,  supposing  them  to  be  the  result,  not  of  nervous, 
but  of  organic  irritation.  If  experience  should  have  demonstrated 
the  perfect  inefficiency  of  this  system,  the  patient  is  often  aban- 
doned to  the  miserable  influences  of  alcoholic  or  narcotic  stimuli, 
to  the  injury  of  mind,  heart,  and  body. 

Excision. — Under  the  influence  of  disappointment  or  the  ineffi- 
ciency of  medicinal  agents  on  the  one  hand,  and  under  fear,  on 
the  other,  that  the  patient  will  be  exhausted  by  pain,  by  leucor- 
rhoea,  by  hemorrhage,  or  that  the  tumors  will  inflame  and  suppu- 
rate or  eventually  assume  a  malignant  character.  Dr.  Washington 
L.  Atlee,  of  this  city,  has  boldly  resorted  to  the  scalpel,  with  all 
its  immediate  and  remote  dangers,  to  effect,  if  possible,  a  radical 
cure. 

Two  locations  have  been  chosen  for  the  operation — one,  for 
distinction,  may  be  termed  vaginal ;  the  other,  abdominal.  The 
first  is  regarded  as  preferable  in  all  cases  where  the  tumors  are 
towards  the  lower  part  of  the  uterus,  or  intra-uterine;  the  second 
is  resorted  to,  when  they  are  on  the  external  surface  sessile  or 
pedunculated. 

In  the  vaginal  operation,  sometimes  the  tumor  can  be  directly 
reached;  but  in  most  cases  the  canal  of  the  neck  is  to  be  enlarged 


EXCISION    OF    UTERINE    TUMORS.  457 

by  bougies,  by  sponge  tents,  by  incisions  with  a  bistoury  or  the 
"hysterotoine."  Then,  a  division  of  the  cyst  or  capsule  being 
made,  the  tumor  is  to  be  enucleated  by  the  fingers,  by  scoops, 
knives,  or  forceps,  as  completely  as  possible.  These  vaginal 
operations  have,  during  the  last  few  years,  been  frequently 
repeated,  and  often  modified.  Mr.  Baker  Brown,  for  example,  has 
maintained  that  simple  division  of  the  sides  of  the  cervix  by  the 
scissors,  is  often  sufiicient  to  arrest  the  hemorrhage.  In  other 
instances,  he  contents  himself  with  a  simple  division  of  the  cyst 
inclosing  the  tumor,  stating  that  the  bleeding  will  then  often  cease, 
and  in  some  cases  the  tumor  will  be  gradually  dissipated.  In 
other  cases,  disintegration  of  the  mass  of  the  tumor  being  accom- 
plished, a  sloughing  process  ensues.  The  mass  may  be  discharged 
spontaneously,  or  the  process  of  evulsion  by  hooked  forceps  in- 
stituted. 

The  success  of  this  operation,  although  still  countenanced  by 
some  distinguished  names,  does  not  appear  to  be  so  great  as  was 
anticipated.  Many  good  authorities  condemn  it  as  being  danger- 
ous, occasionally  fatal,  and  often  useless. 

Without  dwelling  upon  the  usual  dangers  of  surgical  opera- 
tions, arising  from  pain,  hemorrhage,  inordinate  inflammation, 
abscesses,  and  exhaustion — without  fixing  attention  on  the  pecu- 
liar difficulty  of  successfully  operating  deep  in  the  interior  of  the 
body,  where  vision  can  afford  no  effectual  assistance,  and  the  sense 
of  touch  can  alone  enable  the  surgeon  to  distinguish  healthy  from 
morbid  tissues — and  without  alluding  to  the  danger  of  injuring 
the  bladder  in  front,  and  the  rectum  and  peritonasum,  as  they  are 
in  contact  with  the  vagina  and  uterus,  posteriorly — -the  objections 
to  this  operation,  perhaps  under  any  circumstances,  are  radical. 

The  operation,  although  sometimes  easily  performed,  and  with- 
out any  unpleasant  succedanea,  must  always  be  regarded  as 
serious,  and  frequently  dangerous,  from  the  importance  and  mor- 
bid state  of  the  tissues  concerned,  and  their  proximity  to  the 
bladder,  the  rectum,  and  especially  to  the  peritonaeum. 

A  dangerous  operation  should  never  be  performed  until  there 
is  some  imperative  necessity.  Does  such  a  necessity  exist?  This 
question  we  have  already  answered  when  we  explained  how  the 
pain,  hemorrhage,  inability  to  walk,  the  nervous  and  wretched 
condition  of  the  patient,  depended,  not  on  the  nature  and  charac- 
ter of  the  tumor,  but  mainly  on  the  weight  and  pressure  of  the 


458      TREATMEISTT — COMPLICATION'S    OF    DISPLACEMENTS. 

enlarged  mass  upon  the  perinaeum,  rectum,  nerves  of  the  sacrum, 
etc.  Therefore,  by  removing  such  pressure,  the  irritation  may 
be  relieved,  and  its  consequences  be  dissipated.  This  is  our 
theory,  suggested  as  well  as  confirmed  by  much  experience.  It 
is  not  invalidated  by  the  assertion  that  such  tumors  may  increase, 
and  may  destroy  life ;  for  the  answer  is  conclusive,  that  often 
no  increase  occurs ;  that  if  they  do  augment,  the  whole  mass  will 
then  rise  above  the  brim  of  the  pelvis,  by  which  it  will  be  sup- 
ported without  the  intervention  of  even  a  pessary.  The  patient 
is  very  comfortable,  and  ought  not  to  be  terrified  by  the  assertion 
that  the  tumor  may  grow  sufficiently  to  destroy  life  by  its  enor- 
mous size  ;  for,  such  cases  are  so  rare  that  few  practitioners  have 
ever  met  with  them,  and  are  far  counterbalanced  in  number  by 
those  in  which  these  tumors  have  remained  quiescent  for  years, 
or  have  spontaneously  diminished  or  disappeared. 

Neither  should  the  fears  of  the  unfortunate  patient  be  disturbed 
by  anxieties  of  the  possible  occurrence  of  inflammation  or  malig- 
nancy in  such  tumors.  These  are  very  unusual  occurrences  ;  in- 
deed, we  are  disposed  to  say,  even  more  infrequent  than  the  occur- 
rence of  inflammation  and  malignancy  in  the  uterus  itself,  in  the 
mammas,  or  other  original  tissues.  Certainly  it  is  a  fundamental 
error  to  suppose  that  hard  fibrous  or  steatomatous  tumors  are 
either  originally  or  subsequently  prone  to  assume  a  cancerous 
action.  Their  natures  are  distinct  ah  initio.  Cancer  has  its  own 
origin  and  its  own  progress ;  and  although  morbid  tissues  may 
occasionally  suffer  from  a  cancerous  diathesis,  so  may  healthy 
tissues  also,  and  this  possibility  affords  therefore  no  just  founda- 
tion for  surgical  operations.  The  far  greater  probability  is,  that 
no  such  malignancy  will  ensue ;  that  the  tumors  will  remain 
quiescent,  and  may  even  vanish. 

Another,  and  perhaps,  it  may  be,  a  more  conclusive  and  radical 
argument  against  these  surgical  operations  on  uterine  tumors,  is 
the  general  fact  that  they  can  seldom,  if  ever,  be  satisfactorily ' 
completed.  Without  discussing  the  question  whether  any  sur- 
geon has  sufficient  skill,  tact,  and  delicacy  of  touch,  to  rerrfove 
all  the  diseased  tissues;  yet,  the  general  truth  is,  we  believe, 
conceded,  that  these  uterine  tumors  are  very  rarely  isolated.  If 
there  be  one,  there  are  generally  several,  in  various  stages  of 
development.  Thence,  if  one,  two,  or  more  be  completely  de- 
stroyed, what  security  can  be  honestly  given  that  the  patient  is 


EXCISION    OF    UTERINE    TUMORS.  459 

safe,  and  that  the  apprehended  dangers  from  hemorrhage,  inflam- 
mation, or  cancer  no  longer  exist  ?  Certainly  none ;  for  so  long 
as  a  single  minute  tumor  exists,  the  patient  is,  of  course,  in  the 
same  danger.  It,  according  to  these  views,  is  liable  to  the  same 
development  and  the  same  results.  Such  remaining  tumors 
cannot  be  always,  or  indeed  usually,  detected,  as  they  are  often 
entirely  beyond  reach,  in  the  substance  or  on  the  exterior  of  the 
uterus. 

These  vaginal  operations,  therefore,  to  remove  uterine  tumors, 
must,  very  frequently,  be  altogether  useless,  even  in  cases  of 
apparent  or  reputed  success.  They  are,  however,  not  simply 
useless,  but  often  injurious  not  merely  from  the  pain  and  irrita- 
tion, the  inflammation  and  abscesses,  which  may  be  their  conse- 
quences, but  from  the  danger  of  aggravating  the  supposed  bad 
character  of  these  morbid  growths.  If  a  blow  upon  a  tumor  in 
the  breast  will  hasten  its  development,  why  should  not  the 
excitement  of  the  uterus  and  its  morbid  growths  be  disturbed 
by  the  incomplete  efforts  for  their  relief?  The  nervous  and  vas- 
cular irritations  thus  generated,  must  facilitate  the  development 
of  any  tumors  which  remain,  and  any  morbid  predisposition  to 
which  they  may  be  liable. 

Eecoveries  are  said  to  have  resulted  from  these  operations ;  and 
drawings  are  presented  of  the  supposed  condition  of  the  uterus, 
before  and  after  the  extirpation  of  the  excrescence. 

That  patients  very  generally  recover  from  these  vaginal  opera- 
tions may  be  readily  conceded,  notwithstanding  the  forced  dilata- 
tion and  incision  of  the  cervical  canal,  the  enucleating  of  the 
tumor  by  the  fingers  and  scoop  of  the  surgeon,  and  the  dragging 
with  forceps,  as  this  organ  is  wonderfully  tolerant  of  all  such 
severe  irritations. 

It  will  however  require  a  vast  amount  of  most  careful  investi- 
gation, and  of  reiterated  and  prolonged  experience,  to  determine 
how  far  the  distressing  symptoms,  which  had  existed  prior  to  the 
operation,  have  been  destroyed,  and  how  far  the  patient's  general 
health  has  been  improved;  how  far  such  improvement  is  attri- 
butable to  the  spontaneous  disappearance  which  is  sometimes 
observable,  or  to  the  greater  development  by  which  the  whole 
mass  is  elevated  above  the  superior  strait  of  the  pelvis,  and  thus 
the  symptoms  of  displacement  relieved ;  and,  finally,  how  far  such 
reported  recoveries  are  permanent,  or  how  soon  the  patient  falls 


460      TREATMENT — COMPLICATIONS    OF    DISPLACEMENTS. 

again  into  the  same  miserable  state  from' the  development  of  the 
untouched  tumors  in  other  parts  of  the  organ. 

In  review  of  the  facts  and  observations  already  detailed — in 
support  of  the  opinion  that  the  urgent  symptoms  depend  on  the 
pressure  downward  or  backward  (prolapsus  or  retroversion)  of 
the  .enlarged  organ,  and  not  upon  the  character  of  these  adventi- 
tious growths — the  operation  does  not  appear  to  be  justifiable, 
perhaps  in  no  case,  certainly  not  until  a  scientific  and  judicious 
trial  with  pessaries  has  entirely  failed  to  relieve  the  neuralgic, 
menorrhagic,  and  hemorrhagic  symptoms.  Several  such  cases 
the  author  has  watched  for  years,  the  patients  partaking  of  the 
ordinary  business  and  pleasures  of  life,  until  the  climacteric 
period,  when  hemorrhages  have  ceased,  and  general  health  has 
been  quite  restored,  and  the  tumor  has  become  more  or  less  atro- 
phied, old  age  being  passed  in  comfort. 

The  abdominal  operation  also  has  been  proposed,  and  been 
boldly  if  not  rashly  executed.  The  cavity  of  the  abdomen  being 
exposed  by  suitable  incisions,  and  the  omentum  and  intestines 
being  sufficiently  displaced,  the  operator  removes  all  the  pedun- 
culated tumors,  or  incises  and  enucleates  the  sessile. 

If  two  or  three  tumors  exist,  the  operation,  as  just  described, 
is  comparatively  simple ;  but  in  a  great  number  of  instances  the 
tumors  are  very  numerous,  some  in  the  walls  of  the  uterus,  and 
often  the  whole  organ  is  completely  enveloped  with  adventitious 
growths,  even  of  larger  size  than  the  uterus  itself.  Moreover, 
close  peritoneal  adhesions  often  exist,  converting  the  uterus,  the 
tumors,  and  the  surrounding  tissues  into  one  mass.  In  other 
varieties,  the  whole  abnormal  growth  involves  the  proper  tissue 
of  the  womb,  as  in  the  case  of  Mrs.  H.,  already  detailed,  which, 
although  sometimes  free,  is  not  unfrequently  bound  down  by  close 
adhesions. 

Diagnosis,  in  such  cases,  must  always  be  very  limited,  nothing 
but  actual  exploration  can  evolve  all  their  complications.  Never- 
theless surgeons,  encouraged  by  some  partial  successes,  and  by 
the  advantages  derived  from  ani»sthesia,  boldly  make  their  inci- 
sions, have  no  hesitation  in  breaking  up  the  adhesions,  and  when 
confronted  with  the  terrible  fact  that  these  tumors  cannot  be  re- 
moved without  the  ablation  of  the  uterus,  at  once  resolve  to 
throw  the  ligature  or  the  chain  of  the  ecraseur  over  the  cervix 
uteri,  to  enable  them  to  remove  the  whole  conglomerated  mass. 


EXCISIOX    OF    UTERINE    TUMORS.  461 

Strange  to  Sc\y,  some  such  patients  have  escaped.  Perhaps  the 
most  remarkable  case  on  record  is  one  given  by  Dr.  H.  E.  Storer, 
of  Boston,  Massachusetts,  in  which  a  woman  recovered  after 
having  had  the  uterus,  the  Fallopian  tubes,  and  the  tumor 
weighing  thirty-seven  pounds,  all  of  which  was  closely  connected 
with  the  surrounding  tissues,  removed.  How  far  the  success,  in 
this  instance,  will  be  productive  of  good  or  evil,  time  must  de- 
velop ;  many  have  already  perished  under  similar  attempts  both 
in  Europe  and  America ;  perhaps  some  might  have  lived  for  many 
years  with  much  comfort  and  even  health,  if  the  operation  had 
not  been  performed. 

Mr.  I.  Spencer  Wells,  the  celebrated  ovariotomist  of  London, 
on  a  visit  to  this  country  in  the  autumn  of  1867,  declared  that 
he  had  performed  gastrotomy  several  times  for  fibrous  tumors, 
but  with  very  little  success.  He  concludes,  therefore,  it  had  better 
be  hft  alone,  except  in  extreme  cases  of  hemorrhage,  or  pressure 
on  a  vital  organ. 

This  operation  is  one  of  no  great  difficulty  in  the  execution, 
but  one  certainly  pregnant  with  dire  consequences. 

It  is  liable  to  most  of  the  objections  detailed,  in  regard  to  the 
vaginal  operation,  which  need  not  be  repeated,  and  to  peculiar 
dangers  arising  from  the  tissues  involved,  and  the  cavity  exposed. 

If  wounds  of  the  vagina  and  uterus  can  be  made  with  impunity, 
this  is  rarely  true  of  wounds  of  the  peritoneum,  a  serous  mem- 
brane of  immense  extent,  covering  very  important  viscera,  and 
prone  to  rapid  and  diffused  inflammation.  The  danger  of  peri- 
tonitis is,  in  such  cases,  aggravated  by  more  or  less  effusion  of 
blood  among  the  intestines,  where  it  may  putrefy  from  the  pre- 
sence of  atmospheric  air ;  by  the  wounds  made  in.  removing  the 
pendent  tumors ;  by  the  contusions  and  lacerations,  caused  by 
the  process  of  enucleation ;  by  the  sloughing  of  any  undetached 
portions  of  the  tumors.  That  any  patient  should  escape  death, 
would,  ci  priori,  be  regarded  as  wonderful  in  view  of  the  well- 
known  dangers  of  acute  peritonitis.  Should  extensive  inflam- 
mation not  occur  at  once,  the  patient  may  be  exhausted  from 
continuous  chronic  inflammation  and  fistulous  abscesses. 

It  also  should  be  remembered,  that  patients  who  might  thus  be 

.destroyed  by  these  bold  operations,  would  probably  never  have 

suffered  from  the  presence  of  such  growths;  and  that  many  such 

have  actually  passed  through  a  long  life  with  perfect  impunity. 


462       TEEATMENT — COMPLICATIONS    OF    DISPLACEMENTS. 

It  is  therefore  dilBcult  to  conceive  how  a  practitioner,  in  foro 
scientiae  vel  conscientise,  can  be  justified  in  subjecting  his  patient 
to  these  imminent  perils.  The  introduction  of  anaesthetics  may 
have  done  much  to  diminish  these  dangers;  but  they  still  remain, 
and  naught  but  extreme  necessity,  which  in  these  cases,  we  be- 
lieve, does  not  exist,  will  justify  the  risk. 

Another  collateral  objection  is  very  important,  namely,  the 
difliculty  of  diagnosis,  not  merely  as  to  the  number  of  tumors  and 
their  location,  but  even  as  to  their  existence.  In  all  abdominal 
tumors  the  diagnosis  is  uncertain.  This  general  declaration  may 
seem  singular  to  the  inexperienced,  or  even  to  the  experienced 
practitioner,  who  has  acquired  much  confidence  in  his  own  skill. 
Yet,  in  a  long  professional  life,  we  have  heard  so  many  discordant 
opinions  from  men  of  undoubted  science  and  experience,  and  so 
much  unavailing  and  sometimes  dangeroas  practice,  resulting 
from  a  false  diagnosis  as  regards  the  various  forms  of  abdominal 
swellings,  as  to  justify  the  declaration,  just  made,  of  the  uncer- 
tainty of  diagnosis  in  cases  of  tumors  within  the  abdomen. 
Pregnancy  has  been  mistaken  for  encysted  or  peritoneal  dropsy, 
so  that  upon  performing  paracentesis  abdominis,  the  puncture  has 
been  made  into  a  pregnant  uterus.  Gastrotomy  has  been  per- 
formed for  ovarian  tumors,  which  proved  to  be  uterine,  or  even 
where  no  tumor  of  any  kind  existed,  "veotus  et  praeterea  nihil." 

Cases. — In  a  consultation  held  some  twenty  years  ago,  positive 
opinions  were  offered  by  three  out  of  four  experienced  surgeons 
and  accoucheurs,  in  a  case  of  an  abdominal  swelling  of  some 
twelve  years'  duration,  according  to  the  account  of  the  patient. 
By  one  it  was  regarded  as  an  extra- uterine  pregnancy;  by  a 
second  as  a  uterine  growth;  by  a  third  as  an  ovarian  tumor; 
while  the  fourth  would  not  unite  with  any  of  his  colleagues. 

Again,  we  were  consulted  by  Mrs.  H.,  a  widow  lady  of  some 
thirty-five  years  of  age,  who  had  sufl'ered  from  nervous  affections 
for  many  years,  and  her  general  health  had  been  injured  by 
almost  every  variety  of  regular  and  empirical  practice.  We 
found  a  hard  abdominal  swelling,  chiefly  on  the  left  side;  but 
having  passed  a  long  flexible  metallic  probe  for  some  eight  inches 
into  the  uterus,  we  satisfied  ourselves  that  the  tumor  was  uterine. 
Our  advice — to  attend  carefully  to  her  general  health,  and  to 
abandon  all  attempts  to  destroy  the  tumor — was  neglected.  She 
placed  herself  for  some  six  months  under  the  care  of  an  empiric, 


EXCISION    OF    UTERINE    TUMORS.  463 

and  became  mucli  exhausted  bj  his  treatment  and  by  the  con- 
tinued development  of  the  tumor.  She  now  consulted  an  expe- 
rienced surgeon,  and  also  an  accoucheur  of  a  neighboring  city. 
They  decided  that  the  tumor  was  ovarian.  Six  months  after- 
wards she  died  in  convulsions.  A  necropsy  revealed  an  immense 
solid  tumor  developed  from  the  left  half  of  the  uterus,  and  occu- 
pying chiefly  the  left  portion  of  the  abdomen ;  the  upper  part  of 
the  tumor  formed  two  prominences,  as  if  it  were  bilobed.  The 
other  half  of  the  uterus  was  greatly  attenuated ;  the  cavity  was  at 
least  ten  inches  in  the  longitudinal  diameter,  and  the  whole  mass 
was  estimated  to  weigh  twenty  pounds,  and  was  of  a  fibrous 
character. 

We  are  now  in  attendance  upon  a  lady,  who  for  some  ten  years 
has  been  a  martyr  to  nervous  diseases,  and  who  has  been  succes- 
sively attended  by  several  of  the  leading  physicians  in  Philadel- 
phia, for  uterine  irritations,  and  abdominal  and  pelvic  tumors; 
and  here,  also,  a  similar  discrepancy  of  opinion  has  existed  as  to 
the  presence,  or  as  to  the  location  or  character  of  the  morbid 
growths. 

As  doubtless  sucli  facts  are  familiar  to  every  practitioner,  it  is 
useless  to  multiply  examples;  for,  certainly,  every  prudent  and 
conscientious  man  should,  however  positive  might  be  his  own 
opinion,  choose  to  have  his  diagnosis  confirmed  by  some  expe- 
rienced co-laborer  in  the  field  of  human  suffering,  before  resort- 
ing to  this  abdominal  operation. 

If  the  views  we  have  presented  be  correct,  that  the  symptoms 
resulting  from  these  heterologue  growths  chiefly  arise,  not  from 
their  nature,  but  from  pressure  on  the  pelvic  tissues,  and  hence, 
that  intra-vaginal  supports  are  very  generally  not  only  adequate 
to  their  relief,  even  during  a  long  life,  but  are  far  more  certain 
and  safe  than  a  resort  to  such  dangerous  operations  as  proposed, 
and  that,  too,  on  a  doubtful  diagnosis ;  it  may  be  hoped  the  cause 
of  suffering  humanity  will  be  promoted,  although  less  eclat  may 
redound  to  the  profession  in  the  eyes  of  the  public,  than  is  ob- 
tained by  dazzling  heroic  achievements  with  the  scalpel.  The 
progress  of  science  should  diminish  the  frequency  of  surgical 
operations.     This  is  true  "Conservative  Surgery," 


404      TREATMENT — DISPLACEMENTS    OF    THE    OVARIES. 


CHAPTER   IX. 

TREATMENT   OF   ENLARGEMENTS   AND   DISPLACEMENTS   OF 
THE   OVARIES,    ETC. 

The  importance  of  vaginal  supporters  has  not  yet  been  fully 
detailed,  altliough,  perhaps,  many  will  believe  that  it  has  already 
been  unduly  magnified. 


ENLARGEMENTS  OF  THE  OVARIES. 

Displacements  of  enlarged  ovaries  are  occasionally  observed 
with  or  without  displacements  of  the  uterus.  Ovarian  tumors 
often  cause  descent  or  version  of  the  uterus,  from  their  pressure 
on  this  organ  in  various  directions.  They  induce,  not  unfre- 
quently,  a  lateral  displacement  which  has  not  been  here  noticed, 
as  by  itself  it  seems  to  be  of  no  importance;  the  trouble  in  such 
cases  is  not  from  the  uterus,  but  from  the  ovary. 

Diagnosis. — The  diagnosis  of  ovarian  tumors  is  sometimes 
easy,  but  is  often  surrounded  w:ith  difficulties;  for,  an  enlarge- 
ment of  an  ovary  must  have  attained  considerable  size  before  it 
can  be  detected  by  any  physical  examination.  It  has  been  sug- 
gested, that  if  it  could  not  be  felt  per  vaginam  on  the  side  of  the 
uterus,  it  might  be  reached  per  rectum,  by  a  finger  distending 
the  anterior  wall  of  the  rectum,  and  bent  up  behind  the  uterus 
and  broad  ligament,  so  as  to  reach  the  natural  location  of  the 
ovary.  This  the  author  believes  to  be  impracticable ;  certainly 
all  his  attempts  have  entirely  failed.  The  distance  from  the  anus, 
along  the  rectum,  to  the  upper  portion  of  the  broad  ligament, 
greatly  exceeds  that  of  the  index-finger,  whatever  allowance  may 
be  made  for  the  yielding  of  the  perineal  tissues.  In  addition, 
great  resistance  is  made  by  the  contraction — often  spasmodic — of 
the  muscles^ at  the  outlet  of  the  body,  and  of  the  muscular  fibres 


DIAGN"OSIS    OF    OVARIAN    TUMORS.  465 

of  the  rectum ;  moreover,  a  displacement  of  the  uterus,  and  the 
involuntary  bearing-down  efforts  of  the  patient,  often  increase  the 
difficulty.  These  obstacles  are  excessively  enhanced  by  the  sen- 
sibility of  the  tissues,  especially  of  the  rectum  and  the  uterus,  so 
that  rectal  examinations  are  usually  very  painful. 

When,  however,  the  tumor  is  larger,  by  a  digital  vaginal 
examination  it  can,  with  proper  attention,  be  recognized  on  the 
side  of  the  uterus,  or  at  the  upper  extremity  of  the  vagina  on  the 
side  of  and  behind  the  cervix  uteri.  Of  course,  also,  in  such 
cases  it  is  recognizable  per  rectum,  but  not  so  satisfactorily  as 
per  vaginam.  The  weight  of  the  enlarged  ovary,  and  the  super- 
incumbent pressure  from  the  intestines  and  abdominal  muscles, 
cause  its  displacement,  usually  downwards  and  backwards,  so  as 
to  press  upon  the  pyriform  muscle  and  the  great  ischiatic  plexus 
of  nerves.  In  very  many  of  such  cases  the  tumor  cannot  be 
detected  by  any  external  or  abdominal  examination.  When  of 
great  size,  it  can  usually  be  felt  not  only  per  vaginam,  but  also 
through  the  hypogastric  walls ;  and  when  the  enlargement  is  still 
greater,  the  tumor  is  chiefly  felt  in  the  abdomen,  lying  above  the 
superior  strait,  and  not  interfering,  at  least  materially,  with  the 
tissues  and  organs  of  the  pelvis. 

In  all  cases,  however,  much  care  is  demanded  in  determinino- 
the  true  character  of  abdominal  swellings,  as  has  already  been 
maintained  when  speaking  of  uterine  tumors.  Mistakes  have 
been  so  frequently  made,  by  even  scientific  and  experienced  men, 
as  to  the  nature  of  pelvic  and  abdominal  tumors,  that  it  becomes 
every  one  to  be  very  careful  in  his  investigations,  and  very 
modest  in  uttering  a  positive  opinion.  Still,  by  the  history  of 
the  case,  by  the  external  and  internal  examinations,  by  the  judi- 
cious use  of  a  uterine  probe,  and  by  the  existing  symptoms,  a 
prudent  physician  will  not  often  commit  any  practical  error. 

Pathology, — The  nature  of  these  ovarian  enlargements  need 
not  now  be  discussed ;  it  may  be  left  to  the  morbid  anatomist  or 
the  pathologist.  Suffice  it  to  say,  that  allusion  is  now  made  to 
those  comparatively  solid  tumors  of  the  ovaries,  where  there  is 
no  inflammation,  no  abscesses,  no  dropsical  or  gelatinous  collec- 
tions, and  no  malignant  disorganization.  Such  cases  are  by  no 
means  uncommon,  and  usually  remain  in  a  very  quiescent  state, 
not  perceptibly  enlarging  even  for  years,  and  sometimes  actually 
80 


466      TREATMENT — DISPLACEMENTS    OF    THE    OVARIES. 

decreasing  in  size.  They  usually  possess  no  sensibility,  espe- 
cially when  so  large  as  to  be  above  the  superior  strait ;  but 
sometimes,  when  low  in  the  pelvis,  they  are  very  sensitive  and 
irritable,  so  that  the  least  pressure  on  them  gives  acute  pain. 
This  morbid  sensibility  we  have  known  to  exist  even  for  years, 
without  further  increase  of  size  or  induration,  and  no  inflamma- 
tion or  suppuration  occurring. 

When  these  ovarian  tumors  in  the  abdominal  cavity  are  very 
large,  some  trouble  may  arise  from  their  weight  and  pressure ; 
but,  great  allowance  must  be  made  for  the  nervous  apprehension 
of  females  when  they  know  that  they  have  a  tumor.  The  ima- 
gination and  fears  of  the  patient  are  excited,  and  ready  credence 
is  given  to  idle  tales,  or  to  any  account  of  accidents  and  opera- 
tions connected  with  such  swellings.  The  mere  idea  of  a  "  tumor" 
is  sufficient  to  destroy  their  peace  of  mind.  It  is  a  difficult  task 
to  allay  their  apprehensions,  and  to  make  such  women  believe 
what  their  daily  experience  for  years  should  have  taught  them, 
that  such  enlargements  are  innocuous. 

Exceptions  to  these  remarks  of  course  exist.  Such  tumors 
may  inflame,  may  suppurate,  may  excite  peritonitis,  and  perhaps 
may  become  malignant.  These  results  are  comparatively  rare, 
certainly  in  our  experience,  and  may  be  predicated  of  healthy  as 
well  as  diseased  tissues,  of  a  normal  as  well  as  an  abnormal  con- 
dition of  the  ovaries. 

It  is  possible — and  such  cases  are  said  to  have  occurred — that 
ovarian  tumors,  unconnected  with  deposits  of  water,  gelatinous 
matters,  pus,  or  other  analogous  substances,  may  continue  to 
enlarge,  so  as  to  interfere  with  the  functions  of  the  arteries,  veins, 
and  of  the  abdominal  and  thoracic  viscera,  and  thus  destroy  life. 
Few  practitioners  have  met  with  such  cases,  and  they  ought  not 
therefore  to  be  anticipated.  Ovarian  tumors  of  every  size  often 
remain  for  years,  without  apparent  enlargement  or  decrease. 
The  process  of  development  is  always  very  slow,  and  that  also  of 
diminution.  Besides,  cases  are  reported  in  which  these  swellings, 
after  a  lapse  of  years,  have  greatly  diminished  or  even  disap- 
peared. If  practicable,  it  would  be  interesting  and  useful  to 
establish  the  law  of  increment  and  decrement,  or  what  would 
probably  be  more  within  a  reasonable  expectation,  the  causes  of 
the  development  and  of  the  subsidence  of  ovarian  degenerations. 


PATHOLOGY    OF    OVARIAX    TUMORS.  467 

Displacements. — An  increase  of  the  size  and  weiglit  of  these 
ovarian  tumors  necessarily  causes  displacement ;  in  the  early 
stages  the}^  sink  into  the  cavity  of  the  pelvis,  but  when  large  they 
rise  above  the  superior  strait,  into  the  abdomen,  precisely  as  the 
uterus  ascends  after  the  fourth  month  of  utero -gestation.  The 
latter,  or  what  has  been  termed  the  upper  displacement  of  ovarian 
tumors,  is,  according  to  our  experience,  a  matter  of  comparatively 
small  importance.  The  tumor  in  itself  is  quiescent,  neither  in- 
flamed nor  sensitive,  and  not  even  perceptible  to  the  conscious- 
ness of  the  patient,  by  its  pressure  or  weight.  She  knows  of 
its  existence,  merely  by  her  increase  of  size,  and  by  feeling  the 
swelling  with  her  hands.  It  may  indeed  have  existed  for  years 
without  her  knowledge.  Perhaps  every  practitioner  of  much 
experience  has  met  with  such  cases.  The  writer  has  often  de- 
tected these  ovarian  tumors  in  patients,  whose  physicians,  as  well 
as  themselves,  had  no  suspicion  of  their  existence.  The  patient 
feels  well  and  attends  to  her  usual  occupation  without  distress. 
It  would  be  unnecessary  to  detail  cases  of  the  kind.  We  will 
merely  allude  to  a  preparation  in  our  obstetric  museum,  sent  by 
Dr.  Thornton,  of  Mississippi ;  it  is  an  enlarged  ovary,  which  had 
been  gradually  converted  into  a  solid  calcareous  mass,  of  an 
elliptical  shape,  six  inches  and  a  half  in  length,  by  four  inches  in 
its  transverse  or  conjugate  diameter,  and  one  pound  and  twelve 
ounces  in  weight.  It  was  taken  from  the  body  of  a  negro  woman, 
who  had  never  complained  of  any  inconvenience  from  its  presence 
during  life. 

The  other  class  of  cases  are  those  where,  from  the  small  size  of 
the  enlarged  ovaries,  they  do  not  rise  out  of  the  cavity  of  the 
pelvis.  In  this  circumscribed  cavity,  containing  the  bladder,  the 
uterus,  and  the  rectum,  and  having  its  internal  parietes  covered 
by  innumerable  ramifications  of  bloodvessels  and  nerves,  origin- 
ating from  some  of  the  largest  trunks,  vascular  and  nervous,  in 
the  economy,  very  various  effects  are  frequently  observed.  These 
effects  may  be  slight  symptoms,  hardly  recognizable,  or  alBfections 
often  exceedingly  distressing,  and  sometimes  it  may  be  serious ; 
they  depend  on  various  conditions  of  the  tumor,  of  the  pelvic 
viscera,  and  the  general  temperament  or  state  of  the  patient. 

As  an  ovary  enlarges,  gravity,  in  addition  to  the  superincum- 
bent pressure,  causes  its  descent  on  the  posterior  and  lateral  por- 
tions of  the  pelvis ;  sometimes  it  falls,  even  as  far  as  the  lower 


468      TEEATMENT — DISPLACEMENTS    OF    THE    OVARIES. 

portion  of  the  sacro-sciatic  foramen,  that  is,  to  the  floor  of  the  pel- 
vis.    This  constitutes  the  downward  displacement  of  an  ovarj. 

By  this  displacement  of  an  enlarged  ovary,  pressure  is  neces- 
sarily made  on  the  broad  ligament,  pushing  it  forward,  so  that 
an  anteversion,  or,  more  frequently,  a  lateral  displacement  of 
the  uterus,  is  produced ;  on  the  veins  of  the  pelvis,  causing  a 
passive  congestion  of  their  radices,  especially  in  the  uterus  and 
extremity  of  the  rectum ;  finally,  and  this  is  the  most  important 
fact,  pressure  is  made  on  the  nerves  of  the  pelvis,  on  the  obtu- 
rator nerve,  and  on  that  wonderful  plexus  of  nerves,  at  the  ischi- 
atic  opening,  the  largest  plexus  in  the  body,  connected  below 
with  every  tissue  of  the  pelvis  and  lower  extremity,  and  above 
with  the  spinal  and  cerebral  centres,  and  thus,  with  the  whole 
animal  economy. 

Complications. — These  displaced  ovaries  are  not  unfrequently 
complicated  with  displacements  of  the  uterus,  with  anteversion,  or 
anteflexion,  as  above  mentioned,  and  with  prolapsus  or  retrover- 
sion, without  or  with  flexion ;  all  of  which  render  the  diagnosis, 
but  especially  the  symptoms  and  treatment,  more  obscure  and 
difl&cult. 

Another  complication  is  not  very  unfrequently  observed,  an 
irritable  condition  of  the  ovary,  thus  enlarged  and  displaced,  arising, 
doubtless,  from  the  continual  pressure  against  the  walls  of  the  pel- 
vis, the  uterus,  etc.  The  word  irritable,  or  morbidly  sensitive  is 
used,  because  great  pain  is  often  excited  by  a  touch  from  the 
finger,  or  a  pessary,  and  yet  no  other  phenomena  of  inflamma- 
tion is  developed,  even  after  the  lapse  of  many  years. 

Case. — A  lady  from  New  Orleans  presented  herself  to  our  care, 
with  a  displaced  uterus,  which  proved  to  be,  unexpectedly,  difiicult 
to  manage.  She  complained  of  much  soreness  and  pain  in  the 
left  side  of  the  pelvis.  It  was  not  relieved,  but  often  aggravated 
by  the  presence  of  a  pessary.  A  careful  examination  detected  a 
body  nearly  flat,  and  apparently  about  one  and  a  half  inches  in 
diameter,  sensitive  on  pressure,  hard,  very  movable,  and  lying  on 
the  plane  of  the  left  ischium.  The  patient  was  relieved  of  all 
suffering  by  modifying  the  form  of  the  pessary,  so  as  not  to  press 
against,  but  under,  this  swelling,  and  thus  to  elevate  it.  Years 
afterwards,  we  had  an  opportunity  of  examining  this  patient,  and 
found  the  same  tumor,  rather  less  in  size,  but  still  somewhat 
sensitive  on  pressure. 


CASES    OF    OVARIAN    TUMORS.  469 

The  symptoms  of  irritable  ovaries  are  so  analogous  to  those  of 
irritable  and  displaced  uterus,  and  the  two  accidents  are  so  fre- 
quently coincident,  that  a  diagnosis  can  only  be  made  by  a  careful 
pelvic  examination  ;  even  then  it  will  be  often  difficult  to  deter- 
mine what  degree  of  sympathetic  disturbance  is  dependent  on  the 
ovarian  and  what  on  uterine  irritation. 

Perhaps  the  symptoms  will  be  best  illustrated  therefore  by 
allusion  to  a  few  cases  in  which  the  displaced  ovary  was  involved, 
with  less  or  more  of  uterine  disturbance. 

Cases. — A  lady  from  the  South,  the  wife  of  a  physician,  came 
to  Philadelphia  complaining  of  feelings  of  languor  and  debility, 
with  uncomfortable  sensations  of  pressure.  Her  husband  sus- 
pected scirrhus  of  the  womb,  as  he  had  detected  an  enlargement 
in  the  pelvis.  The  uterus  was  in  a  proper  position,  though 
slightly  hypertrophied ;  but  there  was  a  hard  ovarian  tumor  on 
the  right  side,  pressing  forward  the  broad  ligament.  A  pessary 
placed  under  the  uterus  and  tumor  relieved  her  disagreeable  sen- 
sations. She  was  thus  enabled  to  exercise  with  impunity.  Some 
ten  years  afterwards,  we  had  an  opportunity  of  examining  this 
case,  and  found  the  ovary  had  rather  decreased  in  size,  and  had 
never  given  any  sensible  trouble.  The  lady  is  still  living  and 
enjoying  comfortable  health. 

A  far  more  deplorable  case  afterwards  came  under  our  notice. 
The  whole  nervous  system  of  this  lady  was  broken  down  by  pain, 
morbid  sensations,  and  confinement — chiefly  to  her  bed — for  some 
ten  years,  so  that  her  organic  life  had  also  suffered. 

She  was  pale,  feeble,  ansemic,  and  much  emaciated ;  it  was  with 
difficulty  that  she  could  sit  up  or  move  across  the  room;  she 
experienced  pain  throughout  the  spine,  chiefly  in  the  right  sacral 
region,  together  with  weight,  pressure,  bearing-down  sensations, 
and  pain  on  having  the  bowels  moved.  Her  muscular  energies 
were  prostrated;  her  sensations  were  all  morbid,  especially  as 
regarded  her  brain ;  she  was  troubled  with  neuralgic  pains  about 
the  head  and  eyes,  frequent  headaches,  and  confusion  of  thought ; 
she  could  not  read  or  think,  and  could  not  sleep,  except  for  short 
periods ;  when  awake,  especially  if  excited  or  in  much  pain, 
she  would  have  spectral  illusions,  "  persons  appearing  before  her 
for  hours  at-  a  time,  talking,  and  usually  upon  disagreeable  sub- 
jects." The  slightest  mental  or  moral  exertion  would  be  mani- 
fested by  an  effusion  of  tears. 


470      TREATMENT — DISPLACEMENTS    OF    THE    OVARIES. 

She  was  by  nature  and  education  a  remarkably  delicate  and 
refined  woman,  and  with  strong  religious  feelings.  She  had  been 
the  mother  of  three  living  children ;  the  youngest  was  then  about 
five  years  of  age.  Many  of  her  friends  regarded  her  as  more 
diseased  mentally  than  bodily.  She  had  leucorrhoea,  occasional 
menorrhagia,  and  a  hypertrophy  of  the  uterus.  We  were  sur- 
prised to  find  very  little  displacement  of  this  organ ;  it  was  slightly 
prolapsed,  and  deviated  somewhat  towards  the  left  side ;  but  deep 
in  the  right  sacro-sciatic  notch  over  the  pyriform  muscle  there 
was  an  enlarged  and  displaced  ovary.  No  swelling  could  be 
detected  by  an  external  examination. 

She  was  ordered  a  nutritious  and  digestible  diet,  laxatives, 
tonics,  sponging  with  cold  water,  and  frictions,  with  cool  and 
astringent  vaginal  injections.  Pessaries  of  varied  forms  and 
power  were  employed,  so  as  gradually  to  elevate  the  tumor  from 
its  bed  on  the  sacro-sciatic  plexus  of  nerves.  The  patient  was 
encouraged  to  make  as  much  muscular  effort  as  consistent  with 
her  weakness  and  morbid  sensations.  Her  improvement  was 
soon  manifested,  so  that  at  the  first  ensuing  catamenial  period  she 
was  surprised  and  delighted  to  find  that  the  spectral  illusions  had 
entirely  vanished.  The  case  was  of  course  tedious ;  great  atten- 
tion had  to  be  paid  to  the  mechanical  arrangements  of  the  pessa- 
ries, so  as  to  accomplish  the  desired  object  without  pain  or  irrita- 
tion. General  comfort  and  the  ability  to  move  about  were  obtained, 
and  although  circumstances  have  prevented  her,  sometimes  for 
two  years  at  a  time,  from  having  proper  medical  attention,  yet 
she  mentally  and  corporeally  has  enjoyed  good  health,  and  is 
now  regularly  pursuing  her  important  duties  with  trifling  mental 
or  physical  disturbance.  In  the  last  examination,  the  tumor  was 
not  nearly  so  perceptible ;  whether  from  a  diminution  in  size,  or 
because  more  elevated,  could  not  well  be  determined.  The  ex- 
periment of  abandoning  the  internal  support  has  been  several 
times  tried,  but  ineffectually.  Uncomfortable  sensations,  pains, 
and  mental  disturbances  have  soon  called  for  its  restoration. 

Another  lady,  whose  children  were  numerous  and  had  arrived 
at  maturity,  resigned  to  them  the  family  domicile,  under  the  feel- 
ing that  her  days  were  soon  to  terminate.  She  was  weak,  pale, 
and  unable  to  move  about  without  pain  in  the  left  iliac  fossa,  near 
the  spine  of  the  ischium,  and  over  the  left  gluteal  muscles  and 
down  the  limb,  so  that  the  difficulty  of  walking  was  very  great. 


CASES    OF    OVARIAN    TUMORS.  471 

The  catamenia  had  not  appeared  for  years,  but  there  was  some 
leucorrhoea.  She  had  lost  flesh,  but  was  still  corpulent.  There 
was  found  a  slightly  prolapsed  uterus  of  rather  a  large  size,  and 
also  a  hard  swelling  behind  the  left  broad  ligament,  which  could 
by  careful  manipulation  externally  be  perceived  in  the  left  por- 
tion of  the  hypogastric  region. 

This  patient  immediately  began  to  improve  upon  the  use  of 
pessaries,  and  under  the  influence  of  tonics,  fresh  air,  and  after- 
wards of  sea  bathing.  Exercise,  which  could  not  be  borne  before 
the  mechanical  support  was  employed,  now  was  taken,  not  only 
with  impunity,  but  with  great  comfort  and  advantage.  At  this 
date  she  continues  very  well,  and  able  to  travel  about  at  pleasure. 
Occasionally,  the  old  pains  in  her  side,  nates,  and  limb,  with  some 
lameness,  returns ;  but  by  changing  or  readjusting  the  pessary 
these  pains  disappear,  so  that,  although  corpulent  and  some  sixty 
years  of  age,  she  takes  considerable  exercise. 

The  ovarian  swelling  is  no  longer  to  be  recognized  by  either 
an  external  or  an  internal  examination.  This  may  be  explained 
partly  by  its  being  smaller,  and  partly  from  the  increased  obesity 
of  the  abdominal  region,  as  well  as  by  the  elevation  of  the  tumor 
in  the  pelvis  by  the  constant  use  of  a  pessary  for  years.  The 
actual  disappearance  of  the  tumor  can  hardly  be  suspected ;  inas- 
much as  pain  and  lameness,  from  irritation  of  the  sacro-ischiatic 
nerves,  return  when  no  adequate  support  is  given. 

A  delicate  emaciated  lady  from  the  far  south,  some  time  since, 
presented  herself  in  Philadelphia.  For  years  she  had  been  the 
subject  of  pelvic  irritations,  and  for  many  months  of  menorrhagia. 
She  was  nervous  and  anaemic.  She  had  been  treated  by  leading 
physicians,  north  and  south,  for  inflammation  and  ulceration  of 
the  OS  and  cervix  uteri,  by  nitrate  of  silver.  This  caustic  plan 
was  carried  further  than  was  intended,  and  to  such  an  extent  that 
the  OS,  originally  quite  patulous,  was  diminished  so  as  hardly  to 
admit  a  small  sized  probe.  The  uterus,  upon  examination,  was 
found  to  be  about  the  natural  size,  slightly  anteflexed ;  but  a  hard 
and  sensitive  enlargement  of  the  ovary  was  detected  on  the  right 
side,  and  behind  the  neck  of  the  uterus.  The  case  was  treated 
by  means  of  a  pessary,  during  the  use  of  which,  with  the  occa- 
sional assistance  of  a  tampon,  the  menorrhagia  was  checked,  and 
a  steady  improvement  was  manifested.  The  menses  soon  were 
delayed  till  their  regular  period,  and  lasted  but  seven  days.     At 


472      TREATMENT — DISPLACEMENTS    OF    THE    OVARIES. 

the  end  of  three  months  the  patient  returned  home,  too  soon  to 
judge  what  would  be  the  final  result,  but  better  than  she  had  been 
for  years  under  difierent  treatment. 

A  patient  who  had  been  an  invalid  for  two  years,  and  consi- 
dered as  the  subject  of  acute  ovaritis,  wbicb  terminated  in  an 
abscess,  and  had  left  her  very  weak  and  nervous,  came  to  Phila- 
delphia, and  placed  herself  under  our  care  in  February.  She 
was  liable  to  diarrhoea,  had  some  dyspepsia,  and  the  least  pain  or 
agitation  produced  great  sensations  of  debility  with  hysteric 
symptoms.  There  was  a  slight  prolapsus  uteri,  a  trifling  leucor- 
rhoea ;  and  an  irritable  tumor  was  found  on  the  right  of  the 
uterus,  projecting  towards  the  horizontal  ramus  of  the  pubis. 
The  anterior  portion  of  this  tumor  can  be  felt,  by  an  external 
examination,  behind  and  above  the  insertion  of  Poupart's  liga- 
ment. Some  six  weeks  have  elapsed,  and  this  patient  regards 
herself  as  quite  well,  being  able  to  walk  about  at  pleasure,  and 
without  inconvenience;  she  has  few  or  no  nervous  symptoms, 
and  has  gained  strength,  color,  and  flesh.  A  pessary  is  worn 
w^ithout  discomfort,  and  the  tumor  remains  as  yet  without  appa- 
rent change. 

The  following  case  will  illustrate  the  symptoms  of  a  very  acute 
and  severe  character,  in  which  there  was  a  retroversion  of  the 
uterus  with  an  irritable  and  displaced  ovary  on  the  right  side. 
How  far  the  symptoms  were  referable  to  the  uterus  or  the  ovary, 
or  to  their  conjoint  influences,  must  be  doubtful ;  but  that  much 
depended  upon  the  ovary  seems  to  be  proved  by  its  analogy  with 
cases  already  detailed,  and  by  the  great  disability  of  the  right 
limb ;  but  especially,  because,  long  after  the  retroversion  was  re- 
lieved, the  nervous  and  muscular  irritation  of  the  right  limb  in 
some  degree  continued,  with  much  irritation  of  the  brain,  eyes,  etc. 

A  lady,  about  thirty-five  years  of  age,  of  healthy  aspect,  good 
color,  flesh,  and  muscle,  who  had  always  enjo3'ed  fine  health, 
and  great  activity,  with  the  exception  of  dysmenorrhoea  and 
nervous  headaches  from  early  life,  began  in  the  winter  of  1857-8 
to  suffer  from  dyspepsia  and  symptoms  of  spinal  irritation.  In 
the  ensuing  spring  they  rapidly  increased,  so  that  by  the  month 
of  May  she  was  disabled  and  prostrated.  For  ten  months  her 
sufferings  gradually  augmented.  At  first  she  could  move  about 
for  short  distances  on  crutches,  but  the  sitting  posture  could  not 
be  tolerated.      Afterwards,  she  was  confined  constantly  to  bed 


CASES    OF    OVARIAN    TUMORS.  473 

from  severe  neuralgic  and  spasmodic  affections  of  the  lower 
extremities,  particularly  of  the  right ;  this  last  was  drawn  up 
towards  the  body,  and  had  to  be  supported  by  pillows ;  the  least 
attempt  to  extend  it  was  intolerable.  There  was  great  pain  in 
the  sacral  region,  in  the  right  nates,  in  the  right  and  left  iliac 
fossae,  with  great  soreness  on  pressure,  and  utter  inability  to  turn 
in  bed  from  the  severe  suffering  which  was  felt  on  every  attempt 
even  to  move  her.  There  was  great  dysuria,  intense  suffering 
and  faintness  on  every  evacuation  from  the  rectum ;  much  of  this 
pain  in  defecation  was  referred  to  the  left  side  of  the  umbilical 
region  near  the  navel.  Great  pain  was  experienced  in  the  dorsal 
and  the  upper  portion  of  the  cervical  regions  of  the  spine,  with 
consequential  neuralgia  in  the  arms,  and  inability  to  use  them 
even  to  feed  herself.  There  was  also  tenderness  on  pressure  over 
various  parts  of  the  spine. 

The  brain  suffered  exceedingly,  as  exhibited  by  intense  nerv- 
ous, "crazy"  headaches,  by  confusion  of  thought,  morbid  percep- 
tions, inability  to  read,  and  often  incapability  of  understanding 
or  attending  to  what  was  read.  There  were  so  much  neuralgia 
and  sensibility  in  the  eyes  that  they  could  not  be  used ;  and  the 
sense  of  smell,  often  acute,  was  sometimes  so  perverted  that  she 
insisted  that  her  clean,  luxurious  apartments  were  surrounded 
with  putrefying  bodies.  This  morbid  disturbance  of  the  olfactory 
nerves  was  sometimes  very  transitory,  existing  for  a  few  hours, 
and  then  disappearing.  Shortness  of  breathing,  asthmatic  symp- 
toms, and  aphonia,  were  often  present,  and  sometimes  so  great 
that  her  whispers  were  heard  with  difficulty.  There  was  much 
cardiac  disturbance ;  but  some  of  the  most  intense  suffering  was 
produced,  or  perhaps  rather  aggravated,  by  the  state  of  the  sto- 
mach. There  was  nausea,  loss  of  appetite,  frequent  retchings, 
occasional  vomiting  of  any  food  that  might  be  taken,  but  chiefly 
of  watery  and  glairy  mucus,  though  the  quantity  was  not  great. 
Occasionally,  after  much  straining,  some  bilious  matters  appeared, 
and  not  unfrequently  the  fluids  were  acid.  Her  nervous  energy 
was  much  prostrated,  and  as  the  gastric,  spinal,  and  leucorrhoeal 
distress  gradually  increased,  fears  were  entertained  that  her  life 
was  endangered.  At  the  catamenial  periods  the  agony  was  in- 
tense, and  the  nervous  exhaustion  excessive.  Nevertheless,  the 
patient  did  not  lose  much  flesh,  had  no  fever,  and  maintained 
even  a  good  condition  of  her  blood  and  circulation ;  she  had,  to 


474      TREATMENT — DISPLACEMENTS    OF    THE    OVARIES. 

be  sure,  a  frequent  and  irritable  pulse,  but  sufficiently  strong  and 
full. 

She  was  considered  and  treated,  by  most  experienced  and  ex- 
cellent physicians,  as  a  case  of  spinal  neuralgia,  or  spinal  irrita- 
tion ;  and  the  diagnosis  seemed  to  be  confirmed  by  a  great  sensi- 
tiveness over  particular  spots  in  this  region.  At  these  places  the 
least  pressure  gave  exquisite  pain.  Her  able  physician  resorted 
with  perseverance  to  all  the  usual  remedies  of  local  bleeding, 
counter-irritation,  poultices,  liniments,  bathing,  and  internally  he 
employed  laxatives,  alteratives,  tonics,  stimuli,  narcotics,  and 
antispasmodics.  Few  of  the  narcotic  articles  could  be  tolerated. 
The  cannabis  Indica  proved  to  be  the  most  comforting  and 
effectual  in  producing  sleep  and  some  repose.  In  February, 
1859,  the  symptoms  had  become  so  aggravated — there  was  so 
much  pain,  and  the  nausea  and  retching  were  so  constant  by  night 
and  day — that  no  continued  sleep  could  be  produced,  and  it  was 
not  thought  by  her  friends  that  she  could  live  from  one  day  to 
another. 

Her  physician  now  suspected  that  there  was  some  pelvic  irri- 
tation, and  being  confirmed  in  his  opinion  by  an  examination, 
he  committed  the  case  to  our  care.  The  sensibility  of  the  pelvic 
tissues  was  exceedingly  great,  without  any  unnatural  or  super- 
abundant secretions;  the  fundus  of  the  uterus  was  low  down 
towards  the  inferior  portion  of  the  sacrum,  the  os  nteri  pointing 
to  the  OS  vaginae,  and  the  cervix  slightly  flexed.  After  some 
days  of  treatment  by  a  pessary,  great  mechanical  resistance  was 
detected  behind  and  to  the  right  of  the  womb,  where  there  was 
then  discovered  the  enlarged  ovary  as  a  hard  body,  rounded, 
slipping  under  the  finger,  and  exquisitely  sensitive. 

Believing  that  the  displacement  of  this  enlarged  ovary  on  the 
right  side  of  the  uterus  was  the  real  cause  of  the  irritations  of 
the  pelvic  viscera,  of  the  sacral,  spinal,  and  cerebral  disturb- 
ances, with  all  the  reflex  influences  on  the  nerves  of  the  senses, 
lungs,  heart,  stomach,  and  extremities,  the  indication  was  clear 
to  remove  such  displacement,  and  the  consequent  pressure  on 
sensitive  tissues,  notwithstanding  the  great  tenderness  of  the 
vagina,  uterus,  etc.  This  idea  was  at  once  cautiously  acted  upon, 
to  the  abandonment  of  all  other  treatment — as  the  organic  actions 
of  the  patient  were  good — except  the  occasional  exhibition  of  a 
pill  of  cannabis  Indica,  and  some  moderate  stimuli.     Very  small 


CASES    OF    OVARIAN    TUMORS.  475 

instruments  were  at  first  employed,  and  afterwards  those  wlncli 
were  larger  and  more  powerful,  as  the  tissues  yielded  to  pressure. 
It  was  soon  found,  however,  that  a  great  mechanical  resistance 
existed,  especially  from  the  ovary,  which,  in  conjunction  with 
the  extreme  irritability  of  all  the  tissues,  and  the  difficulty  of 
avoiding  undue  pressure  on  the  rectum  and  nerves  below,  and 
the  ovary  and  uterus  in  front,  afforded  a  combination  of  diffi- 
culties seldom  to  be  encountered.  The  result,  however,  has  been 
most  gratifying,  not  merely  in  the  relief  of  the  patient,  but  in 
confirming  the  great  practical  principle,  that  by  relieving  sensi- 
tive tissues  from  pressure,  local  and  general  nervous  irritations 
will  subside. 

The  stomach,  in  a  few  days  after  the  use  of  a  pessary,  was 
greatly  relieved ;  food  could  be  readily  taken  and  retained,  and 
sleep,  hitherto  interrupted  by  the  constant  retching,  was  enjoyed, 
very  generally  without  an  anodyne.  All  the  miserable  sensa- 
tions of  the  brain,  with  the  reflex  influences  on  other  organs, 
were  moderated.  The  recovery  has  been  steadily  progressing, 
with,  of  course,  alternations  from  various  causes,  especially  at 
the  catamenial  periods,  which  still  bring  much  pain,  and  occa- 
sionally some  of  the  old  symptoms,  such  as  aphonia,  perverted 
smell,  cephalalgia,  etc.  It  would,  perhaps,  be  interesting  to  the 
physiologist  to  point  out,  with  precision,  the  regular  succession 
of  improvement ;  but  here  we  can  merely  say  that  the  distress  in 
the  spine  rapidly  diminished;  the  tenderness  over  the  vertebrae, 
and  the  pain  soon  followed ;  and  then  she  obtained  some  com- 
mand of  the  right  lower  extremity,  with  more  ability  to  turn  in 
bed ;  a  very  gradual  increase  of  capability  to  extend  this  limb, 
and  afterwards  to  move  it  in  bed ;  then  the  power  to  have  her 
head  elevated,  and  more  activity  of  her  mind,  so  that  she  could 
enjoy  being  read  to.  In  about  three  months  she  could  move 
about  her  room  on  crutches,  and  once  more  take  pleasure  in  the 
society  of  her  friends.  Several  troublesome  symptoms  were  long 
in  disappearing ;  the  pain  near  the  umbilicus  in  defecation  con- 
tinued for  some  six  months,  but  has  entirely  disappeared ;  the 
pain  in  the  eyes,  especially  that  irritability  of  the  nerve  which 
prevented  her  reading  or  using  her  needle,  was  very  persevering, 
as,  indeed,  is  quite  common  in  these  uterine  troubles,  it  would 
occasionally  disappear  for  days,  and  even  weeks,  and  then  would 
return.     An  analogous  and  usually  simultaneous  disturbance  of 


476      TREATMENT — DISPLACEMENTS    OF    THE    OVARIES. 

the  brain,  with  distress  of  various  kinds,  was  also  very  persistent, 
and  even  still  occasionally  returns,  and  is  to  her  the  most  dis- 
tressing symptom.  The  inability  to  sit  comfortably  was  also 
slow  in  disappearing,  and  even  this  spring  a  peculiar  cushion  is 
often  required. 

In  September,  1859,  her  powers  of  progression  began  decidedly 
to  improve,  at  first  by  means  of  crutches;  but  by  the  end  of  Oc- 
tober she  could  readily  walk  about  her  room  without  any  artificial 
support.  In  January  of  this  year,  she  walked  out  of  doors,  and 
soon  was  able  to  walk  a  mile,  or  even  further ;  but  a  soreness,  or 
rather  weakness,  in  the  right  ankle,  forced  her  to  walk  very 
slowly ;  of  late,  however,  her  ability  to  walk  rapidly  is  continually 
increasing.  Occasionally  there  is  uneasiness  in  sitting  down,  and 
some  trouble  about  the  brain  and  eyes.  All  of  which  symptoms 
are  gradually  diminishing,  both  in  frequency  and  intensity.  At 
the  present  time,  October,  1860,  she  is  able  to  walk  from  two  to 
three  miles  a  day,  with  ease  and  rapidity;  the  right  ankle  has 
gained  strength ;  very  little  uneasiness  is  produced  by  the  sitting 
posture,  and  with  the  exception  of  some  disturbances  of  the  head 
and  eyes,  and  some  suffering  at  her  catamenial  periods,  she  ap- 
pears to  be  well,  and  has  resumed  her  usual  domestic  and  social 
duties. 

All  the  phenomena,  from  the  beginning  of  her  suffering,  have 
been  manifestly  dependent  on  the  pressure  of  the  ovarian  tum.or, 
the  uterus  or  the  pessary,  one  or  all,  upon  the  pelvic  tissues. 
Just  in  proportion  as  such  pressure  was  moderated,  changed  or 
removed,  has  been  the  diminution,  the  alteration,  or  disappear- 
ance of  special  symptoms.  Sometimes  the  pain  in  the  right  limb 
would  be  increased  or  diminished;  sometimes  there  would  be 
more  of  the  umbilical  pain  from  the  act  of  defecation,  then  it 
would  diminish ;  frequently  the  head  and  eyes  would  be  relieved, 
then  become  a  source  of  annoyance.  Vaginal  examinations  and 
operations  were,  therefore,  continually  demanded,  to  alter  the 
form  or  the  size  of  the  pessary,  or  to  change  the  points  of  pres- 
sure so  as  to  alleviate  or  destroy  the  suffering. 

The  slow  progress  of  the  case  has  been  entirely  due  to  a  fixed 
position  of  the  ovary — whether  from  adhesions  or  other  cause, 
cannot,  of  course,  be  positively  ascertained — so  that  it  yielded 
very  slowly  to  the  pressure  of  the  pessary ;  frequently  it  over- 
came this  pressure,  and  made  the  instrument  impinge  against 


ANOMALOUS    CASES.  477 

other  tissues,  causing  irritations.  This  difficulty  not  unfrequently 
exists,  even  in  ordinary  cases  of  retroversions  of  the  uterus,  from 
the  fundus  being  firmly  fixed  in  its  unnatural  positions.  In  all 
such  cases  great  patience  and  perseverance  are  demanded.  No 
force  can  be  employed,  as  the  pain  and  inflammation  excited 
would  be  intolerable  and  dangerous ;  but  by  careful  and  frequent 
attention,  any  sign  of  inflammation  may  be  avoided,  until  all 
pressure  from  the  tumors  is  gradually  and  often  entirely  removed, 
to  the  great  happiness  of  the  poor  sujfferer,  whose  mind  and  spirit 
are  even  more  relieved  than  her  body.  The  principle,  that  the 
pessary  should  be  worn  without  exciting  nervous  or  organic  irri- 
tation is  never  to  be  forgotten. 


ANOMALOUS  CASES. 

Anomalous  cases  will  of  course  occur  in  an  extensive  practice. 
Some  of  them  may  be  very  analogous  to  those  of  common  occur- 
rence, and  others  not  readily  to  be  explained,  or  completely 
relieved. 

Of  this  character,  are  enlargements  probably  of  lymphatic 
glands  in  different  portions  of  the  pelvic  cavity,  which  not  only 
maintain  the  symptoms  of  irritation,  but  becoming  excessively 
irritable  themselves,  render  the  treatment  by  pessaries  more  diffi- 
cult.    Instances  of  this  character  have  already  been  detailed.^ 

There  are  other  cases  in  which  after  a  retroverted  or  other 
displacement  of  the  uterus,  ovary,  etc.,  has  been  relieved,  or 
where  no  displacement  originally  existed ;  yet,  the  symptoms  of 
sacral  irritation  from  pressure  were  present,  in  more  or  less 
intensity,  and,  perhaps,  no  cause  could  be  detected  by  investiga- 
tion per  vaginam,  per  rectum,  or  through  the  abdominal  walls ; 
and  where  no  examination  of  the  spinal  column  threw  light  oft 
the  source  of  irritation. 

Such  cases  we  can  imagine  depend  on  various  causes,  such  as 
scybalous  collections  in  the  colon  ;  mesenteric,  ovarian,  or  osseous 
tumors,  too  high  up  from  the  floor  of  the  pelvis,  or  too  deep- 
seated  in  the  abdomen,  to  be  recognized.  Most  of  such  patients 
remain  great  sufferers  for  years ;  any  treatment  has  but  a  pallia- 

>  See  page  219. 


473      TREATMENT  —  DISPLACEMENTS    OF    THE    OVARIES. 

tive  influence  Their  general  liealtli  is  often  very  good ;  and  not 
unfrequentlj  there  is  a  spontaneous  disappearance  of  symptoms, 
especially  at  the  cessation  of  the  catamenia.  'Death  very  seldom 
ensues,  as  the  organic  life  is  often  very  good ;  but,  occasionally, 
from  nervous  dyspepsia,  and  the  consequent  nausea,  vomitings, 
diarrhoeas,  etc.,  secondary  symptoms  may  become  so  severe,  that 
a  life  of  suffering  at  length  finds  relief  in  the  grave. 


TREATMENT. 

From  the  remarks  on  the  cases  above  presented,  it  appears 
that  all  displacements  of  ovarian  and  other  tumors  in  the  cavity 
of  the  pelvis,  producing  nervous  irritation,  should  be  managed 
on  the  same  principles  as  already  indicated  for  the  treatment  of 
uterine  tumors.  Mechanical  measures  must  be  so  arranged,  as  to 
remove  all  pressure  from  the  nerves  of  the  pelvis  or  other  sensi- 
tive tissues. 

In  the  upward  displacements,  however,  of  enlarged  ovaries  into 
the  cavity  of  the  abdomen,  no  other  attention  is  ordinarily  re- 
quired than  is  demanded  for  the  general  health  and  strength  of 
the  patient.  All  attempts  to  discuss  such  tumors,  by  evacuating 
measures  and  by  alteratives  of  any  kind,  prove  useless  as  regards 
the  tumors  and  positively  injurious  as  respects  the  health  and 
strength  of  the  patient.  The  terrible  operation  of  gastrotomy 
for  the  removal  of  such  solid  tumors  is,  we  think,  indefensible: 
inasmuch  as  in  itself,  it  is  very  dangerous  and  often  fatal ;  more- 
over, the  diagnosis  is  necessarily  very  difficult,  it  is  sometimes 
impossible  to  determine  whether  the  swelling  be  ovarian,  uterine, 
mesenteric,  or  even  whether  there  be  any  actual  tumor  present. 
If  an  ovarian  enlargement  could  be  positively  recognized,  who 
can  determine  whether  there  be  not  such  universal  adhesions,  as 
to  render  the  operation  altogether  nugatory  ?  On  the  other  hand, 
most  of  these  patients,  as  has  been  mentioned,  will  enjoy  health 
and  strength,  free  from  irritation  and  pain  even  for  a  long  life, 
when  not  subjected  to  inefficient  drugs,  or  to  the  knife  of  the 
surgeon.^ 

The  question  respecting  ovariotomy  is  dijQferent  when  there  are 

'    Vide  p.  460,  Observations  on  Gastrotomy. 


TREATMENT.  479 

collections  of  watery,  gelatinous,  purulent,  or  other  fluids  in  the 
ovaries;  as  such  cases,  after  the  lapse  of  months  or  years,  are 
generally  fatal.  The  difficulties  of  diagnosis  and  the  dangers  of 
the  operation  may  then  be  carefully  contrasted  with  the  dangers 
to  which  the  patient  is  exposed  by  her  disease ;  and  the  decision 
may  occasionally  be  in  favor  of  the  operation.  Let  it,  however, 
be  remembered  that  some  of  these  ovarian  dropsies  have  disap- 
peared, either  spontaneously  or  under  the  effect  of  remedial  agents. 
A  very  interesting  case  of  the  kind  has  occurred  to  the  author  in 
the  person  of  a  lady,  who  had  an  ovarian  tumor  in  the  left  iliac 
fossa;  pregnancy  supervening,  this  tumor  became  dropsical,  so 
that  when  delivery  occurred  at  term,  the  abdomen  remained 
exceedingly  distended,  with  decided  fluctuation  over  its  whole 
extent.  Under  the  careful  attention  of  our  friend  and  former 
pupil.  Dr.  Ludlow,  to  whom  the  case  was  committed,  the  dropsy 
entirely  disappeared,  and  she  now  enjoys  excellent  health  and 
activity.  The  chief  means  employed  were  tonics,  preparations  of 
iodine  internally  and  externally,  and  moderate  compression  by 
means  of  bandages. 

"We  regret  to  add,  that  since  the  publication  of  the  first  edition 
of  this  work,  and  at  the  end  of  two  years  after  her  apparent  re- 
covery, the  dropsical  effusion  returned,  and  proved  fatal. 

This  whole  subject  of  encysted  dropsy  has  occupied  much  of 
professional  attention  for  some  years.  Experience  seems  to 
prove  that  very  generally  it  is  a  fatal  disease  in  the  course  of  a 
few  years  at  the  farthest,  notwithstanding,  there  are  some  re- 
coveries recorded.  Such  recoveries  have  resulted,  occasionally, 
where  no  remedial  agents  have  been  employed;  in  other  instances, 
where  various  alteratives,  so  called,  especially  iodine,  have  been 
freely  given.  Some  few  patients  have  escaped  in  consequence  of 
an  accidental  fistulous  opening,  insuring  the  evacuation  of  the 
cyst,  and  its  subsequent  contraction.  Surgeons  have  imitated  this 
process  by  establishing  an  artificial  fistula,  and  by  making  pres- 
sure over  the  parietes  of  the  abdomen.  Professor  Kiwisch  has 
operated  in  this  way  per  vaginam.  Dr.  Bainbrigge,  of  Liverpool, 
states  that  in  thirty-eight  cases,  where  an  orifice  was  formed, 
either  artificially  or  spontaneously,  thirty-five  patients  recovered. 
This  is  a  wonderful  success,  although  we  do  not  learn  that  this 
procedure  has  been  extensively  imitated. 

Many  successful  results  have  attended  the  use  of  iodine  injec- 


480      TREATMENT — DISPLACEMENTS    OF    THE    OVARIES. 

tions  into  tlie  cyst.  Public  attention  is  much  engrossed,  however, 
by  the  brilliant  operation  of  ovariotomy ;  and  certainly  the  results 
in  which  the  recoveries  are  said  to  have  reached  from  70  to  80 
per  cent,  are  far  more  favorable  than  could  have  been  reasonably 
anticipated  from  the  well-known  dangers  of  the  operation.  Still, 
ovariotomy  has  been  confined  to  selected  cases,  and  very  often 
shortens  a  life,  which  might  have  been  protracted  for  months  or 
years.  The  operation  has  also  been  attempted,  in  very  many 
instances,  where  it  could  not  be  completed,  owing  to  various  com- 
plications, strong  adhesions,  etc.  Let  it  be  remembered  also  that 
many  patients  have  recovered  by  medical  and  surgical  measures, 
far  less  dangerous  in  their  character ;  and  may  we  not  hope 
that  some  safer,  although  less  splendid,  mode  of  relief  may  be 
devised  ? 


PART  III. 

DISEASES   OF   SEDATION, 


CHAPTER    I. 

SEDATION   AND   ITS   CONSEQUENCES. 

Perhaps  the  design  of  this  work  will  not  be  fully  accomplished 
without  noticing  the  state  of  a  part  or  of  the  whole  system,  di- 
rectly opposed  to  excitement  or  irritation.  Inertia  or  sedation 
may  exist:  as  irritation  is  an  increase  of  the  vital  phenomena  or 
actions  of  a  part  or  of  the  whole,  sedation  is  a  decrease  of  those 
phenomena.  In  a  moderate  or  normal  state,  we  may  say,  it  is 
inertia,  or  torpidity ;  in  a  more  severe  or  morbid  state,  it  is  seda- 
tion. This,  when  extreme,  is  termed  "  collapse."  As  irritation  is 
the  result  of  an  irritant  acting  on  the  irritability  of  a  part,  so 
sedation  is  the  result  of  a  sedative  acting  on  the  same  irritability. 
It  is  a  depression  of  the  organic  or  animal  actions,  or  of  both. 
The  torpor  of  the  extremities,  of  the  surface,  or  of  the  whole 
body,  from  exposure  to  cold,  is  a  very  pure  and  common  example 
of  both  organic  and  nervous  sedation;  as  well  as  the  pallor  and 
coldness  of  the  feet  and  hands,  so  frequent  in  nervous  people,  who, 
with  great  irritation,  it  may  be,  of  the  brain,  have  sedation  in  the 
extremities. 

Sedation  does  not  necessarily  imply  a  loss  of  power  or  debility, 
with  which  it  is  too  often  confounded.  Vital  power  is  the  capa- 
bility of  resisting  injurious  influences,  or  of  enduring  action.  De- 
bility is  the  diminution  of  poAver,  sedation  a  diminution  of  action 
or  excitement.  The.  reaction  which  follows  the  exposure  to  cold 
air  or  water  manifests  an  abundance  of  vital  power,  often,  indeed, 
an  increase  of  power.  Hence  sedation  is  generally  very  transi- 
tory, rapidly  appearing  and  disappearing,  alternating  speedily 
with  states  of  irritation.  In  excitable  temperaments,  there  is 
31 


482  SEDATION    AND    ITS    CONSEQUENCES. 

sucli  a  sense  frequently  of  depression  and  exhaustion,  that  patients 
and  even  their  friends  are  terrified,  by  the  so-called  "  weakness" 
of  the  sufferer ;  but  in  a  few  minutes,  perhaps,  all  these  sensa- 
tions vanish,  and  the  ordinary  manifestations  of  activity  and 
power  are  observed.  Eeaction  may  rapidly  ensue,  although  not 
unfrequently  it  occurs  more  slowly,  but  still  without  any  real 
diminution  of  strength.  Of  course,  sedation  may  and  often  does 
coexist  with  debility.  Hence,  in  very  weak  persons  sedation  is 
more  serious,  and  may  be  followed  by  prostration  or  collapse, 
that  is,  by  a  loss  of  power  as  well  as  by  a  loss  of  action.  This  is 
a  sinking  or  dying  condition,  or  as  regards  a  portion  of  the  tissues, 
it  is  a  gangrenous  state.  The  proper  designation  is  a  loss  of 
power  or  of  strength,  in  which  sedation  is  a  consequence;  but 
generally  sedation  implies  merely  a  diminution  of  action  or  func- 
tion without  loss  of  vital  tone  or  vigor. 

Oeganic  Sedation. — Every  one  is  familiar  with  examples  of 
sedation  in  the  organic  or  circulatory  system.  Whenever  there 
is  pallor  of  the  skin  or  mucous  membranes,  there  is,  for  the  time, 
a  diminution  of  the  activity  of  organic  life,  of  the  circulation,  and 
of  the  secreting  and  nutritive  functions.  The  pallid,  contracted 
condition  of  the  skin,  its  dryness  and  harshness,  are  evidences  of 
sedation.  Often  also  the  mucous  membranes  of  the  eyes,  nose, 
mouth,  vulva,  rectum,  etc.,  exhibit  the  same  pallor  and  the  same 
diminution  in  the  size  of  their  capillary  vessels.  All  direct  evi- 
dence that  can  be  collected,  and  all  analogy  indicate  the  same 
condition  of  the  internal  organs  in  many  cases ;  hence  we  speak 
of  torpor  of  the  brain,  heart,  lungs,  liver,  stomach,  bowels,  uterus, 
kidneys,  etc.  This  is  organic  sedation ;  whether  the  cause  arise 
directly  or  indirectly;  whether  it  be  primary  or  secondary. 

Neevous  Sedation. — Examples  of  sedation  or  inertia  in  the 
organs  of  animal  life  are  equally  numerous;  but  such  is  the  inti- 
mate connection  between  the  nerves  and  the  bloodvessels,  that  it 
is  not  easy  to  present  pure  examples  of  nervous  sedation,  i.  e.,  of 
diminution  of  nervous  influence  when  the.  circulation  remains 
undisturbed.  Hence  cold  feet  and  hands  from  uterine  or  cerebral 
excitements,  although  primarily  and  essentially  dependent  on  the 
nerves,  indicate  necessarily  torpor  of  the  circulation,  so  that  less 
blood  goes  to  the  part. 


ORGANIC    AND    NERVOUS    SEDATION — CAUSES.       483 

There  are,  however,  examples  of  pure  nervous  sedation,  in  many 
cases  of  functional  amaurosis,  where  the  optic  nerve  is  compara- 
tively or  completely  inefficient,  when  there  is  no  organic  disease ; 
so  also  there  are  analogous  states  of  the  nerves  of  hearing,  smell- 
ing and  tasting,  etc.,  sometimes  transitory,  sometimes  persistent, 
from  the  sedation  of  the  nerves  appropriate  to  these  senses.  In 
early  life,  the  organs  of  generation  in  both  sexes  are  inert,  and 
the  same  torpor  or  inefficiency  returns  in  old  age  with  the  decline 
of  nervous  excitement. 

All  are  conversant  with  the  languor,  lassitude,  "  sensations  of 
weakness,"  characteristic  of  certain  individuals  from  natural  or 
acquired  temperament,  or  resulting  from  inordinate  exercise.  An 
increase  of  this  muscular  languor  may  render  motion  very  diffi- 
cult, requiring  a  powerful  exercise  of  the  will  to  rouse  up  the 
nervous  energies.  In  other  cases  there  is  a  suspension  of  nervous 
influence  altogether,  as  respects  the  nerves  of  sensation,  of  motion, 
or  of  both,  as  from  injuries  of  the  brain,  spinal  marrow,  or  of  the 
nerves  going  to  a  part  or  organ.  This  is  "  paralysis."  The  mus- 
cular tissue  may  be  perfect  in  its  texture  and  organic  action,  but 
the  nervous  influence  is  absent ;  the  muscle  therefore  does  not 
contract,  it  is  in  a  state  of  perfect  sedation.  Physicians  and  sur- 
geons are  familiar  with  cases  of  local  paralysis  of  the  eyelids,  of 
the  face,  of  the  extremities,  of  the  oesophagus,  stomach,  bowels, 
bladder,  rectum,  etc.  Sometimes  there  is  still  sensation,  but  as  in 
injuries  of  the  spinal  marrow,  there  is  often  loss  of  sensation  as 
well  as  of  motion.  In  all  such  cases  there  is  sedation  in  the  parts 
involved,  even  though  the  remote  or  essential  cause  be  of  an 
irritant  character. 

The  sedations  of  a  portion  or  of  the  whole  of  the  nervous 
system  caused  by  various  poisons,  narcotics,  alcoholic  stimuli, 
antispasmodics,  etc.,  are  well  known,  and  are  generally  exemplars 
of  nervous  sedation,  whether  resulting  directly  or  indirectly,  pri- 
marily or  secondarily,  from  the  operation  of  these  agents. 


CAUSES. 

These  examples  of  organic  and  nervous  sedation  indicate  per- 
haps sufficiently  its  causes. 


484  SEDATION    AND    ITS    CONSEQUENCES. 

Indirect. — Thej  are  very  frequently  indirect^  as  from  irrita- 
tions in  one  part  producing  sedation  in  another  tissue  or  organ. 
Sedation  is  often  the  result  of  previous  inordinate  excitement, 
and  is  thus  indirectly  caused  by  the  feelings  of  exhaustion  from 
great  muscular  effort,  the  indulgence  of  animal  passions,  or  the 
relaxing  effects  of  heat,  either  with  or  without  moisture. 

Direct. — Sedation  may  result  directly  from  mechanical  causes, 
as  severe  contusions — as  in  the  "  asphyxiated"  conditions  of  cer- 
tain tissues  from  blows,  or  of  the  brain  in  cases  of  concussion. 

Sedation  also  arises  directly  from  the  abstraction  of  natural 
.stimuli — for  example,  caloric,  as  it  influences  a  portion  or  the 
whole  of  the  body ;  or  oxygen,  as  regards  the  lungs ;  or  the  ab- 
sence of  food  from  the  stomach,  of  bile  from  the  intestines,  of 
mental  and  moral  excitements  from  the  brain,  etc. 

Again,  direct  sedation  may  be  produced  by  certain  medicinal 
agents,  such  as  sedatives,  narcotics,  and  antispasmodics.  Many  of 
these  articles  act  frequently  indirectly,  as  primarily  there  is  some 
previous  excitement  of  the  nerves,  and  eventually  of  the  blood- 
vessels. 

This  state  of  sedation  is  of  late  very  much  resorted  to  by  sur- 
geons to  lessen  the  pain  and  the  irritations  which  arise  from 
surgical  operations,  usually  termed  "  local  anaesthesia,"  and  is 
effected  by  the  application  of  ice,  or  by  the  "  spray"  of  ether  or 
rhigolene,  or  by  the  carbonic  acid  gas,  the  vapor  of  chloro- 
form, etc. 


CONSEQUENCES  OF  SEDATION. 

The  consequences  of  sedation  vary  from  innumerable  circum- 
stances, especially  from  the  character  and  the  intensity  of  the 
cause,  the  nature  of  the  tissues  concerned,  whether  vascular  or 
nervous,  and  whether  the  influence  exerted  be  on  a  part  or  on 
the  whole  system. 

Generally,  it  may  be  said,  there  is  a  diminution  or  suspension 
of  the  secretions,  excretions,  and  other  functions  of  organic  life, 
when  the  capillary  tissue  is  involved.  Thus,  when  cold  is  applied 
to  a  part,  the  circulation  and  the  organic  actions  diminish  gradu- 
ally, until,  in  extreme  cases,  the  part  is  frozen  or  even  spliace- 


PASSIVE    CONGESTION.  485 

lated.  "When  the  whole  economy  is  involved,  there  is  sedation 
of  the  general  nervous  and  vascular  tissues,  as  indicated  by  the 
diminished  excitement  of  the  pulse,  heart,  muscles,  and  spinal 
and  cerebral  centres,  until  universal  torpor  and  eventually  death 
ensue. 

Influence  of  Nervous  Sedation  on  Organic  Actions. — 
As  regards  the  nervous  sj^stem,  every  degree  of  torpor  may  often 
exist  with  apparent  impunity ;  but,  as  the  nerves  have  physio- 
logically some  control  over  the  organic  actions,  there  is  some- 
times a  disturbance  of  these  actions  in  cases  of  nervous  sedation. 
This  may  perhaps  be  exemplified  by  the  diminished  size  of  para-, 
lytic  limbs,  but  more  especially  by  the  state  of  the  uterus,  ovaries, 
and  mammge  before  puberty,  and  their  atrophied  condition  in  old 
age,  when  the  peculiar  nervous  excitement  and  passions  have  dis- 
appeared. 

Influence  of  Organic  Sedation  on  Nervous  Actions. — 
Sedation  in  organic  actions  has  a  much  more  distinct  influence, 
however,  on  nervous  functions,  inasmuch  as  the  bloodvessels  per- 
meate all  the  organs  of  animal  life  for  their  nutrition  and  suste- 
nance. Hence  any  variation  of  circulation  must  influence  directly 
the  organ,  which  these  vessels  penetrate.  The  cerebrum,  the 
centre  of  animal  life,  is  of  course  dependent  on  the  organic  life  for 
its  nourishment,  development,  and  integrity.  Hence,  although 
the  increased  flow  of  blood  to  the  brain  may  cause  mental  excite- 
ment, delirium,  etc. ;  yet,  it  is  equally  true  that  a  decrease  of 
vascular  determination  will  be  followed  by  a  diminution  of  cere- 
bral activity,  by  faintness,  complete  syncope,  or  even  collapse. 

Passive  Congestion. — In  the  sedation  of  organic  life  the  activity 
of  the  circulation  in  a  part  is  diminished ;  but  it  does  not  neces- 
sarily follow  that  the  quantity  of  blood  in  the  part  is  lessened. 
Frequently  this  is  the  case,  as  already  exemplified  in  the  skin, 
especially  of  the  extremities  after  long  exposure  to  cold.  The 
arterial  circulation  is  diminished,  and  the  veins  are  for  a  short 
time  slightly  turgid,  and  give  a  purplish  hue  to  the  surface,  but 
they  gradually  empty  themselves,  so  that  a  general  pallor  ensues. 

Facts  from  observation  and  experiment,  which  need  not  now 
be  detailed,  prove  that  the  fluids  thus  excluded  from  the  extremi- 
ties and  surface  gradually  accumulate  in  the  large  venous  vessels 


486  SEDATION    AND    ITS    CONSEQUENCES. 

of  the  interior,  in  tlie  brain,  lungs,  heart,  liver,  spleen,  etc. ;  and, 
to  some  extent,  even  in  their  extreme  radicals,  on  the  mucous 
surfaces.  At  the  same  time  there  is,  internally  as  well  as  exter- 
nally, a  deficiency  of  the  quantity  of  blood  in  the  arterial  system, 
namely,  in  the  left  side  of  the  heart,  aorta,  and  its  ramifications. 
The  collection  of  venous  blood  in  the  tissues  is  termed  "  passive 
congestion" — the  accumulation  of  blood  in  a  part,  but  not  an 
increase  of  the  flow  to  the  part. 

Such  passive  congestions  seldom  exist  from  pure  sedation,  except 
in  the  large  cavities  of  the  head,  chest,  and  abdomen ;  but  they 
may  often  be  observed  externally,  from  a  different  class  of  causes, 
as  when  a  ligature  is  thrown  around  the  arm,  in  the  turgescence 
of  the  veins  of  the  lower  extremities,  in  varices  or  from  the  pres- 
sure of  the  gravid  uterus.  Owing  to  the  functions,  and  still  more 
to  the  peculiarities  of  the  venous  circulation  in  the  head,  chest, 
and  abdomen,  passive  congestions  of  the  brain,  heart,  lungs,  and 
the  chylopoietic  viscera,  are  by  no  means  unfrequent. 

Facts  and  illustrations  might  be  easily  adduced ;  but  perhaps 
they  occur  in  the  minds  of  all.  When  oxygen  is  excluded  from 
the  lungs,  asphyxia  results,  which  always  implies  passive  con- 
gestion of  the  pulmonary  artery  and  right  side  of  the  heart,  with 
a  comparative  emptiness  of  the  pulmonary  veins,  and  the  left  side 
of  the  heart.  The  effects  of  this  congestion  are,  by  reason  of  the 
pressure  on  the  organs  involved,  to  increase  the  sedation,  and 
to  cripple  still  further  the  activity  of  their  functions ;  this  pres- 
sure is  often  augmented  by  the  effusion  of  seroid,  mucoid,  or 
bloody  fluids.  These  consequences  of  venous  or  passive  conges- 
tion are  familiar  to  all,  from  the  effects  of  ligatures  to  a  limb ; 
there  is,  first,  venous  turgescence,  then  effusions  of  serum,  then 
of  blood,  and  eventually,  mortification.  So,  in  the  brain,  passive 
congestions  are  followed  by  effusions  of  serum  or  blood,  consti- 
tuting "  venous  or  passive  apoplexy."  Similar  results  are  observed 
in  the  lungs,  liver,  etc.  The  functions  of  the  organs  at  times  are 
so  much  diminished,  that  death  frequently  is  the  consequence. 

In  the  viscera  of  the  chest  and  abdomen,  spontaneous  relief  is 
more  frequently  experienced,  as  the  effusions  may  have  taken 
place  on  exposed  surfaces,  as  the  mucous  membrane  of  the  bron- 
chial tubes  or  of  the  alimentary  canal.  Large  discharges  of  sero- 
mucoid  fluids,  or  of  pure  blood,  escape  through  these  canals,  to 
the  relief,  it  may  be,  to  the  recovery  of  the  patient,  as  is  often 


REACTION.  487 

seen  in  haemoptysis,  hgematemesis,  and  -mekena ;  or  in  some  mode- 
rate cases,  free  expectoration,  or  profuse  emesis  or  catharsis  of 
watery  fluids  is  followed  by  marked  improvement. 

Eeaction. — Eeaction  often,  however,  relieves  sedation.  In 
the  nervous  system,  all  the  varieties  of  pure  nervous  irritation 
and  sedation  are  continually  and  often  with  great  rapidity,  alter- 
nating with  each  other,  as  has  been  frequently  exemplified; — 
nervous  chills  followed  by  flushes  of  heat ;  coldness  or  torpor  of 
the  extremities  appearing  and  disappearing,  with  nervous  head- 
achesj  etc. 

So  also  in  organic  life,  the  cause  being  removed,  or  stimuli, 
natural  or  artificial,  being  employed,  reaction  follows,  sometimes 
moderate,  sometimes  so  severe  that  other  dangerous  accidents 
occur.  After  exposure  to  cold  air,  or  to  cold  water,  the  reaction 
is  moderate,  and  beneficial.  The  individual  feels  better  and 
stronger ;  hence,  the  "  tonic  effects  of  cold" — directly  "  sedative," 
indirectly  "tonic." 

If  the  reaction  be  more  severe,  then  morbid  influences,  inflam- 
matory and  febrile,  are  apt  to  follow.  If,  again,  the  reaction  be 
still  more  sudden  and  severe,  active  congestions,  apoplectic  effu- 
sions, ensue  with  fatal  results  to  a  part  or  to  the  whole.  So  also 
in  idiopathic  fevers,  patients  often  die  in  the  cold  stage,  from 
great  sedation  and  passive  congestion ;  but  often  reaction  occurs, 
developing  the  hot  stage,  sometimes  so  severely,  that  death  results 
from  violent  excitement,  and  active  congestion.^ 

TREATMENT. 

The  treatment  of  sedation  from  this  general  summary  of  its 
nature  and  consequences,  may  be  easily  deduced,  so  far  at  least 
as  the  general  principles  are  involved.  The  details  are,  however, 
often  difficult  of  execution,  and  require  great  judgment  and  much 
experience. 

Stimulation. — The  important  principle  or  indication  is,  to 
stimulate  appropriately  the  depressed  action  of  the  tissues  or 
organs. 

'  A  more  extended  account  of  sedation  and  passive  congestion,  with  their 
consequences,  was  published  by  the  author  in  the  American  Journal  of  the 
Medical  Sciences,  May,  1832. 


488  SEDATION    AND    ITS    CONSEQUENCES. 

In  local  sedations,  direct  and  indirect  measures  are  perhaps 
equally  important. 

Direct  Stimulation  is  demanded  in  cases  of  pallor,  coldness,  and 
other  evidences  of  diminished  circulation  in  the  extremities  or  on 
the  surface  of  the  body;  by  dry  and  moist  heat;  by  frictions, 
especially  with  stimulating  liniments,  rubefacients,  etc.  When 
there  is  much  numbness,  diminution  of  sensibility,  sensations  of 
muscular  weakness,  or  paralytic  symptoms,  in  addition  to  fric- 
tions and  rubefacients,  passive  and  active  motion  should  be 
enjoined,  and  perhaps  direct  or  indirect  electric  or  galvanic  cur- 
rents may  be  advantageous. 

In  sedations  of  the  brain,  mental  and  moral  stimuli  may  be 
conjoined  with  physical  agents.  In  sedation  of  the  lungs,  the 
free  access  of  pure  air  is  essential ;  in  torpor  of  the  stomach,  liver, 
and  bowels,  the  judicious  administration  of  suitable  food  is 
required;  in  all  of  these  cases  much  is  gained  by  the  use  of  mer- 
curial and  other  alteratives,  to  revive  the  activity  of  the  organic 
actions,  functions,  etc. 

Indirect  Stimulation. — As  sedation  so  frequently  arises,  however, 
from  indirect  causes — as  from  irritations  in  other  organs — indi- 
rect measures  are  all  important  in  its  treatment.  The  cause  being 
removed,  the  sedation  disappears;  there  is  a  natural  disposition 
to  this  reaction,  to  an  equalization  of  excitement,  which  is  often 
very  readily  evinced.  In  irritations  of  the  brain,  sedative  mea- 
sures, such  as  leeches,  cups,  cold,  etc.,  to  the  head,  are  not  merely 
advantageous  in  diminishing  cerebral  excitation,  but  also  in 
relieving  the  sedation  of  the  extremities.  Cold  water  to  the  head 
is  as  essential  for  cold  extremities,  as  heat  to  the  feet.  This  prin- 
ciple is  equally  true,  whether  the  cerebral  excitement  be  nervous 
or  organic,  whether  neuralgic  or  inflammatory.  This  general 
truth,  of  course,  applies  to  all  other  analogous  cases,  in  all  parts 
of  the  body,  cseteris  paribus. 

While  acting  on  this  principle,  discretion  should  be  exercised 
to  prevent  a  too  sudden  or  an  excessive  reaction.  In  cerebro- 
spinal affections,  if  the  reaction  be  violent,  subsequent  collapse - 
even  of  a  serious  character  may  be  the  consequence.  While  in 
organic  life,  inflammation,  gangrene,  and  death  may  be  the  result 
of  inordinate  reaction. 

In  general  sedation,  all  the  varieties  of  stimulants  are  usually 
demanded,  not  merely  the  external — as  rubefacients,  etc. — but 


STIMULATION.  489 

the  internal,  as  alcohol,  camphor,  ether,  ginger,  capsicum,  etc., 
assisted  by  alteratives  to  promote  the  capillary  actions,  the  secre- 
tions, and  functions  of  the  various  tissues.  The  danger  of  such 
cases  is  often  very  great,  not  merely  from  the  fact  that  all  the 
vital  organs  are  simultaneously  involved,  but  that  a  passive  or 
venous  congestion  exists,  increasing  the  sedation,  and  interfering 
with  all  attempts  at  reaction.  If,  therefore,  the  case  be  severe, 
no  reaction  ensues ;  all  stimuli,  however  powerful  or  freely 
exhibited,  prove  inefl&cient;  collapse  and  death  follow,  as  is  con- 
stantly observed  in  the  bad  forms  of  venous  congestions  of  the 
brain,  lungs,  heart,  and  even  of  the  chylopoietic  viscera ;  or  in 
the  cold  stage  of  fevers — in  "  congestive  fevers,"  so  called. 
When  the  congestion  is  moderate,  reaction,  whether  spontaneous 
or  artificially  excited  in  the  heart  and  arteries,  is  rapidly  followed 
by  the  relief  of  the  venous  engorgement  of  the  internal  viscera. 
Thus,  in  the  mild  cases  of  asphyxia  in  new-born  children,  or  in 
adults  from  breathing  impure  air  or  immersion  in  water,  a  few 
slight  inspirations,  assisted  by  frictions,  hot  applications,  and  the 
internal  exhibitions  of  stimuli,  are  very  efficient  in  resuscitating 
the  unfortunate  patient. 

In  other  cases  there  are  often  evident  but  ineffectual  attempts  at 
reaction,  even  when  assisted  by  powerful  stimulation.  There  is 
so  much  pressure  on  the  brain,  so  much  distension  of  the  right 
side  of  the  heart,  so  much  contraction  of  the  bronchial  tubes  and 
cells  from  venous  congestion  of  the  lungs,  that  all  efforts  are  in 
vain.  The  organs  are  oppressed  by  the  quantity  of  fluid  in  their 
tissues.  In  such  apoplectic  cases,  experience  has  proved  that 
great  good  is  obtained  by  general  bleeding.  When  a  vein  is 
opened  in  the  arm,  if  the  vital  power  be  not  too  far  exhausted,  dark 
venous  blood  flows,  at  first  very  slowly,  but  then  more  and  more 
freely ;  until,  especially  with  the  help  of  the  usual  internal  and 
external  stimuli,  the  pulse  rises,  and  the  vital  viscera,  being  re- 
lieved of  their  enormous  load,  act  freely,  and  the  danger  is,  at 
least  temporarily,  obviated.  Perhaps  all  have  witnessed  the  de- 
lightful effects  of  this  combination  of  evacuating  and  stimulating 
measures  in  venous  or  passive  apoplectic  conditions  of  the  brain 
and  lungs.  Many  of  the  practitioners  in  Philadelphia,  and  else- 
where, were  very  successful  in  the  sinking  stage  of  cholera  maligna 
by  resorting  to  the  lancet;  they  found  that  the  loss  of  blood  facili- 
tated reaction,  with  the  consequent  disappearance  of  the  watery 


490  SEDATION    AND    ITS    CONSEQUENCES. 

effusions  into  tlie  alimentary  canal,  and  the  muscular  pains  and 
spasms.  The  same  practice  has  been  tried  in  the  cold  or  conges- 
tive stage  of  fevers,  but  by  no  means  with  such  favorable  results. 
If  reaction  be  dangerous  in  cases  of  local  sedation,  it  is,  of 
course,  much  more  to  be  apprehended  in  general  sedation  for 
reasons  now  evident,  and  demands  the  best  exercise  of  the  facul- 
ties of  the  most  experienced  and  judicious  physician,  to  prevent 
effusions,  inflammations,  etc.,  in  vital  organs;  or,  if  such  lesions 
have  ensued,  to  prevent  fatal  results.  Febrile  reaction  may  fre- 
quently be  anticipated,  with  or  without  local  inflammation,  after 
sedation,  and  becomes  more  dangerous  when  with  the  sedation 
there  is  a  real  loss  of  power,  as  in  the  cases  of  fever,  severe  hemor- 
rhages or  long  abstinence.  In  all  such  cases,  the  delicate  task  of 
the  medical  attendant  is  to  moderate  irritation,  without  increasing 
the  exhaustion ;  to  sustain  power  even  by  tonic  medicines  and 
nutritious  diet,  while  action  is  restrained  by  those  anti-febrile 
and  inflammatory  remedies,  which  the  exigencies  of  the  case  may 
demand. 


AMENORKHCEA.  491 


CHAPTER    II. 

SEDATION    OF    THE    UTERU  S.  — A  M  ENO  R  R  H  (E  A  . 

From  these  observations  on  sedation,  tlie  role  which  it  exerts 
in  the  peculiar  diseases  of  women  must  be  very  evident.  It  is 
comparatively  rare,  if  irritation  exists  in  one  organ,  that  sedation 
is  not  present  in  other  organs.  If  there  be  great  cerebral  excite- 
ment, as  in  violent  passions,  nervous  headaches,  etc.,  there  is  gene- 
rally coldness  and  even  pallor  of  the  extremities.  If  puerperal 
convulsions  ensue  during  labor,  there  is  a  comparative  cessation 
of  the  pains  and  contractions  of  the  uterus.  Hence  the  important 
practical  principle  of  "counter-irritation"  is  as  true  in  regard  to 
the  cerebro-spinal  as  the  vascular  system.  To  "equalize"  the  ex- 
citement of  the  nervous  system,  is  as  important  an  indication  as 
to  equalize  the  distribution  of  blood  throughout  the  economy. 
This  is  true,  notwithstanding  the  acknowledged  fact  that  sedation 
or  irritation  usually  involves  a  disturbance  of  the  organic  as  well 
as  of  the  animal  life.  For,  there  can  be  no  doubt  that,  in  numer- 
ous cases,  the  primary  and  important  irritative  disturbance  is 
located  in  the  nerves.  This  nervous  irritation  or  sedation  occurs, 
and  is  then  followed  by  organic  irritation  or  sedation. 

In  a  large  majority  of  the  diseases  of  women,  irritation  of  the 
nerves  is  primary,  sedation  secondary  and  of  minor  importance, 
especially  as  it  usually  exists  in  the  external  surface,  in  the  ex- 
tremities, and  not  in  the  internal  or  vital  organs.  Hence,  under 
such  circumstances,  there  is  very  seldom  passive  congestion  in 
the  external  tissues ;  as  the  blood,  carried  to  the  exterior  in  di- 
minished quantities,  gradually  returns  by  the  veins  with  little 
delay  to  the  interior — leaving  the  surface  pallid,  cold,  or  some- 
times with  a  bluish  tint.  When  reaction  occurs  spontaneously 
or  by  excitants,  the  nervous  excitement  of  the  surface  is  soon 
succeeded  by  a  renewed  activity  and  development  of  the  capillary 
circulation  and  functions. 


492         SEDATION"    OF    THE    UTERUS. — AMENORRHCEA. 

There  are,  however,  cases  of  general  sedation  of  the  nervous 
system  which  demand  some  attention,  and  occasionally  an  analo- 
gous state  of  some  important  viscus,  as  the  uterus,  for  example. 


SEDATION  FROM  MORAL  CAUSES. 

Certain  moral  affections,  as  disappointment,  anxiety,  grief,  fear, 
etc.,  depress  the  excitements  of  the  brain  and  nervous  system. 
Hence,  there  arises  inactivity  not  merely  of  the  mental  and  moral 
being,  but  also  of  the  physical.  There  is  languor,  lassitude, 
weakness,  exhaustion,  indisposition  and  inaptitude  to  muscular 
effort ;  there  are  feelings  of  dulness,  of  fulness  or  vertigo  about 
the  head,  of  oppression,  stricture,  or  even  of  distension  about  the 
heart  and  lungs;  of  similar  sensations  about  the  prsecordia;  of 
loss  of  appetite,  with  flatulency  and  other  dyspeptic  symptoms ; 
torpor  of  the  liver,  stomach,  bowels,  etc.,  with  the  usual  indica- 
tions of  diminished  external  excitement. 

There  is  general  sedation  in  such  cases,  the  inactivity  of  the  heart, 
arteries,  and  capillaries  exists,  as  well  as  of  the  brain;  although 
this  latter,  being  the  organ  of  the  mental  and  moral  feelings,  was 
the  original  source  of  mischief.  This  diminution  of  the  external 
and  internal  circulation,  although  much  more  moderate  than  in 
those  cases  arising  from  cold,  is  accompanied  by  venous  conges- 
tion, which  increases  the  sensations  of  uneasiness  and  fulness  in 
the  head,  chest,  and  abdomen,  and  depresses  still  more  the  activity 
of  the  vital  actions.  Eeaction  may  and  sometimes  does  ensue 
from  change  of  the  thoughts  or  feelings;  but  should  grief  or 
anxiety  be  continued,  the  inaction  will  be  followed  by  serious 
consequences  in  important  viscera.  From  a  trifling  or  depressed 
appetite  and  bad  digestion  follows  deterioration  of  the  blood.  It 
becomes,  therefore,  light-colored,  less  nutritive  and  stimulating. 
This  deterioration  is  increased  by  the  torpor  of  the  liver,  lungs, 
skin,  etc.  The  patient  becomes  "  ansemic,"  so  called,  or  even  "  chlo- 
rotic,"  names  given  to  this  cachectic  state,  from  the  pallid,  bluish, 
bronze,  or  greenish  tinge  given  to  the  tissues.  The  confinement 
to  the  house,  and  the  want  of  fresh  air  and  exercise  aggravate 
the  symptoms ;  so  that  the  patient,  from  this  state  of  melancholy, 
hypochondriasis,  and  despair,  sinks  sooner  or  later  into  those 
chronic  organic  ailments,  varying  with  different  temperaments, 


MORAL    AND    PHYSICAL    CAUSES.  493 

termed  scrofulous,  tubercular,  drojDsical,  etc.  In  many  cases  the 
congestions  of  tlie  heart  are  so  great,  that  hypertrophy  and  other 
chronic  affections  ensue.  The  patient  may,  indeed,  be  said  almost 
literally  to  die  of  a  "broken  heart." 


SEDATION  FROM  PHYSICAL  CAUSES. 

These  cases  of  sedation  with  its  consequences,  anaemia,  chloro- 
sis, etc.,  may  arise  from  physical  as  well  as  moral  causes. 

They  often  depend  on  hereditary  predispositions ;  on  bad  phy- 
sical education,  as  regards  especially  diet,  air,  and  exercise;  on 
all  those  causes  which  indirectly  or  directly  exhaust  power,  as 
from  premature  or  powerful  exertion  of  the  mind,  from  excite- 
ment of  the  passions,  from  great  muscular  efforts,  from  febrile, 
inflammatory,  or  persistent  nervous  affections.  From  this  ex- 
haustion of  power,  of  course,  there  follow  sedation,  congestion, 
and  their  results.  These  sedative  and  atonic  states  at  least  pre- 
dispose, to  disease,  and  are  too  often  followed  by  a  miserable 
train  of  functional  and  organic  complaints. 

If  this  asthenia  exists,  as  is  not  unfrequently  the  case,  in  early 
life,  there  is  no  natural  development  of  the  economy;  at  least 
such  developments  are  slow.  The  usual  age  of  puberty  arrives 
without  there  being  proper  development  of  the  skeleton,  of  the 
adipose  tissue,  of  the  mammae,  uterus,  ovaries,  etc.  The  peculiar 
secretion  from  the  womb  does  not  appear.  Puberty  is  deferred, 
sometimes  for  years.  This  condition  has  unfortunately  been 
termed  emansio  mensium^  as  if  the  failure  of  the  catamenia  was  of 
itself  a  disease,  and  not  merely  one  of  the  signs  of  general  asthenia 
or  sedation. 

This  non-appearance  and  also  the  disappearance  of  the  menses, 
both  of  which  so  universally  treated  of  in  books  as  a  disease, 
cwienorrhoea,  are,  like  dysmenorrhoea,  leucorrhoea,  menorrhagia, 
etc.,  but  indications  of  a  pathological  condition  of  the  uterus  or 
its  appendages,  or  else  of  a  want  of  development  of  these  organs 
or  of  their  non-existence. 

There  is  often,  in  cases  of  non-appearance  of  the  menses,  atrophy 
of  the  uterus,  of  the  ovaries,  and  of  all  the  genitals.  The  age  of 
adolescence  or  womanhood  has  arrived;  but  there  is  no  propor- 
tionate development  of  the  organs  or  functions.     It  is  the  con- 


.494         SEDATIOX    OF    THE    UTERUS. — AMEXORRH(EA. 

tinuance  of  childhood,  a  delay  of  puberty,  and  not  merely  tardy 
menstruation;  for,  all  the  other  characteristic  phenomena  of 
"womanhood  are  also  absent. 

If  these  views  be  correct,  it  results,  necessarily,  that  the  popular 
notion — no  doubt  originally  a  professional  axiom,  and  perhaps 
still  maintained  in  some  quarters — is  unfounded,  namely,  that  the 
non-appearance  of  the  menses  is  the  cause  of  all  this  asthenic  or 
anaemic  state  of  the  system,  leading  to  the  mischievous  idea  and 
injurious  practice,  that  the  flow  is  to  be  brought  on,  in  order  that 
the  health  may  be  restored.  The  reverse  is  the  true  pathological 
and  practical  view;  the  health  must  be  restored,  then  the  organs 
will  be  developed,  and  their  functions  will  be  executed ;  the  ova- 
rian vesicles  will  maturate,  the  uterus  will  respond,  and  men- 
struation will  appear  as  a  sign,  very  significant,  among  others  of 
puberty,  as  well  as  of  restored  health. 

If  amenorrhoea,  the  non-appearance  and  the  disappearance  of 
the  menses,  is,  therefore,  not  a  disease,  but  a  symptom  or  sign  of 
an  abnormal  or  morbid  state  of  the  uterus  or  its  appendages ; 
then  all  attempts  to  induce  the  flow  of  the  catamenia,  without  a 
careful  investigation  of  the  condition  of  the  pelvic  viscera,  are 
unscientific.  They  are  but  little  elevated  above  the  efforts  of  the 
empiric,  which  may  or  may  not  be  successful,  may  be  useful  or 
injurious,  instead  of  being  founded  on  scientific  principles  deduced 
from  the  pathological  state  of  the  organs  involved. 

This  view  is  powerfully  enforced  by  the  fact,  that  girls  may  be 
healthy  and  strong,  in  whom  there  is  not  only  no  appearance  of 
the  menses,  but  in  whom  there  is  no  uterus.  Cases  of  this  kind 
are  upon  record. 

Cases. — During  our  practice,  we  have  met  with  four  cases  in 
which  no  uterus  could  be  discovered. 

The  first  was  a  tall,  thin,  pallid  young  woman,  of  eighteen 
years,  who  had  been  treated  for  "obstruction."  She  felt  well, 
with  the  exception  of  languor;  her  organic  actions  were  good, 
the  external  genitals  and  mammse  moderately  developed ;  but  no 
uterus  could  be  detected.  The  vagina  was  apparently  normal.; 
it  was  about  two  inches  in  length  when  stretched,  but  abruptly 
terminated  as  a  pocket  or  "cul-de-sac."  No  solid  body  could  be 
felt  beyond  it,  by  a  finger  in  the  vagina  or  in  the  rectum,  or  by  a 
sound  in  the  bladder.  The  extremity  of  the  sound  in  the  bladder 
could  readily  be  felt  by  the  finger  in  the  rectum,  the  tissues  of 


ABSENCE    OF    THE    UTERUS. — OBSTRUCTIONS.  495 

these  organs  "being  thus  brought  into  close  contact  above  the 
vaginal  sac.  Several  years  afterwards  we  learned  that  this  lady 
had  married;  but  neither  menstruation  nor  pregnancy  occurred. 

A  second  case  was  under  the  notice  of  many  physicians  in 
Philadelphia,  and  none  could  detect  a  uterus  in  her  pelvis.  She 
was  a  stout,  healthy,  well-developed  young  woman,  of  about 
twenty-six  years  of  age,  and  of  a  fine  ruddy  complexion. 

The  third  case  was  a  married  woman,  of  the  same  age,  in  whom 
neither  menstruation  nor  conception  had  ever  occurred. 

A  fourth  case  we  examined  in  1860.  She  was  a  young  woman, 
who  had  been  married  six  years,  with  good  developments  and 
health,  but  had  never  menstruated  or  conceived.  The  physical 
examination  gave  no  evidence  of  the  existence  of  a  uterus;  the 
vagina  was  about  one  inch  and  a  half  long. 

Atrophy  of  the  uterus  has  often  been  detected  by  examinations 
during  life,  in  cases  of  emansio  mensium.  In  post-mortem  exa- 
minations, not  only  atrophy  of  the  uterus  has  been  seen,  but  also 
of  the  ovaries.  Sometimes  no  uterus  or  ovaries  could  be  dis- 
covered. 

A  further  confirmation  of  the  impropriety  of  treating  amenor- 
rhoea  without  a  proper  investigation  of  the  condition  of  the  pelvic 
cavity,  is  found  in  cases  of  obstruction  of  the  vagina  or  of  the  neck 
of  the  uterus.  In  such  instances  there  is,  at  the  age  of  puberty, 
an  apparent  failure  of  the  menses,  but  there  is  no  real  failure. 
The  menses  are  secreted,  but  not  excreted;  they  are  retained  in 
the  body,  from  the  hymen,  for  example,  being  imperforate.  All 
the  signs  of  puberty  and  of  the  menstrual  nisus  exist,  but  there 
is  no  flow;  month  after  month,  even  year  after  year,  the  symp- 
toms return  without  any  discharge.  The  fluid  accumulates  in 
the  vagina,  or  perhaps  in  the  uterus,  until  a  tumor,  every  month 
enlarging,  is  observed  in  the  abdomen  to  the  discomforture  and 
alarm  of  the  patient  and  her  attendants. 

Case. — The  only  case  we  have  seen  was  that  of  a  thin  and  deli- 
cate young  girl,  fourteen  years  of  age.  The  fluid  seemed  entirely 
confined  to  the  enlarged  vagina,  as  through  the  delicate  parietes 
of  the  abdomen  a  small  body,  apparently  the  uterus,  was  felt 
near  the  umbilicus,  appended  to  an  elliptical  swelling  rising  out 
of  the  cavity  of  the  pelvis.  On  perforating  the  hymen,  a  dis- 
charge of  some  thirty  ounces  of  a  very  thick  dark-purplish  fluid, 
without  any  signs  of  putrefaction,  followed,  the   tumor  imme- 


496         SEDATION    OF    THE    UTEEUS. — A  MENORRHCE  A. 

diately  disappeared,  and  the  supposed  uterus  could  no  longer  be 
detected  through  the  abdominal  walls. 

When  the  obstruction  from  natural  deformity  or  disease  exists 
in  the  upper  part  of  the  vagina  or  in  the  neck  of  the  uterus,  the 
fluid  is  necessarily  confined  to  the  uterus,  and  causes  its  hyper- 
trophy, as  in  pregnancy,  for  which  it  has  unfortunately  been  mis- 
taken. Such  collections  have  also  been  classed  under  the  general 
head  of  "  hydrometra,"  dropsy  of  the  uterus,  from  which  it  must 
be  carefully  distinguished. 

It  is  manifest  how  vain,  and  how  injurious  even,  must  be  all 
medicinal  treatment  of  such  apparent  cases  of  amxenorrhoea  or 
emansio  mensium.  They  are  really  not  medical,  but  surgical 
cases.  They  demand  the  perforation,  or  perhaps  even  the  exci- 
sion, of  the  hymen,  the  removal  of  the  strictures  or  adhesions  of 
the  vagina,  a  puncture,  by  means  of  a  suitable  canula  and  trocar, 
in  the  direction  of  the  canal  of  the  cervix,  or,  it  may  be,  in  some 
very  extraordinary  cases,  into  the  body  of  the  uterus,  per  vaginam 
or  per  rectum. 

If  this  important  principle  be  established — that  amenorrhoea  is 
a  symptom,  and  not  a  disease — the  actual  pathological  condition 
of  the  patient's  general  system,  or  of  the  uterus  and  its  append- 
ages, must  be  examined,  in  order  to  prescribe,  conscientiously  as 
well  as  scientifically,  for  her  relief. 

These  pathological  states  are  innumerable,  but  perhaps  some 
general  arrangement  may  be  made  under  a  few  heads,  and  a  few 
facts  and  illustrations  given  to  assist  in  the  diagnosis  and  thera- 
peutics of  affections  often  obscure  and  troublesome. 

Asthenia. — Amenorrhoea  may  depend  on  asthenia,  a  want  of 
vital  power,  a  state  of  general  atony  attended  by  sedation,  and 
often  by  anaemia,  emaciation,  or  even  chlorosis,  according  to  its 
degree,  persistence,  or  original  and  acquired  complications. 

This  state  has  perhaps  been  sufficiently  alluded  to.  In  minor 
degrees  there  is  merely  tardy  development,  or  debility  resulting 
from  bad  air,  confinement,  want  of  good  food,  or  of  sufficient 
exercise. 

In  a  few  months  or  years,  especially  under  favorable  hygienic 
treatment,  such  as  good,  simple,  nutritious  food,  exercise  in  the 
country,  bathing,  etc.,  the  strength  is  increased;  nutrition  is 
more  rapid ;  the  secretions  and  excretions  become  abundant ;  the 


ASTHENIA.  497 

uterus,  in  common  with  other  organs,  becomes  developed:  and  its 
functions,  in  conjunction  with  those  of  the  ovaries,  are  evolved, 
so  that  menstruation  follows  and  conception  may  ensue. 

In  more  decided  cases  of  anaemia  and  chlorosis,  medicinal 
agents  may  be  required,  in  addition  to  simple  hygienic  measures, 
to  give  tone  to  the  economy,  to  facilitate  the  actions  of  the 
nervous  and  vascular  systems,  the  establishment  of  the  proper 
digestive  and  secretory  functions ;  and  thus  to  purify  and  enrich 
the  circulating  fluid,  and  to  assist  nutrition  and  development. 
These  seem  to  be  the  successive  links  of  this  physiological  chain. 

To  produce  these  desirable  results,  much  can  be  done  in  addi- 
tion to  pure  hygienic  measures.  To  excite  an  appetite,  and  give 
tone  and  activity  to  the  digestive  functions,  so  that  food  may  be 
readily  taken,  and,  when  taken,  be  digested ;  tonics^  from  the  mild, 
bitter  infusions  and  extracts,  to  the  strong  preparations  of  cin- 
chona, iron,  zinc,  copper,  arsenic,  etc.,  become  very  valuable. 

Moreover,  all  that  class  of  remedies,  which,  with  or  without  a 
tonic  influence,  facilitate  the  gradual  development  of  the  secre- 
tory and  nutritive  functions,  and  known  by  the  name  of  altera- 
tives^ are  often  of  great  importance,  such  as  the  alkalies,  ipecacu- 
anha, mercurial  preparations,  the  mineral  acids,  iodine,  and  cod- 
liver  oil.  This  will  also  include  diaphoretics,  diuretics,  and  even 
laxatives.  These  laxatives  are  all-important,  if  judiciously  em- 
ployed; they  should  be  used,  not  as  cathartics  or  purgatives,  or 
direct  evacuants,  which  would  be  positively  injurious,  but  as 
"  peristaltic  persuaders,"  simply  to  obviate  the  sedation  or  torpor 
of  the  muscular  coat  of  the  bowels.  Constipation,  with  all  its 
direct  and  indirect  consequences,  may  thus  be  obviated,  and  no 
positive  exhaustion  or  debility  ensue.  Such  articles  as  rhubarb, 
aloes,  senna,  sulphur,  colocynth,  etc.  which  have  a  tonic  as  well 
as  a  laxative  influence,  are  therefore  to  be  employed.  They  may 
be  advantageously  combined  with  tonics  and  alteratives,  and 
thus  augment  their  direct  and  indirect  advantages  in  restoring 
action  and  strength  to  the  delicate  asthenic  girl. 

This  treatment  for  asthenia  is  equally  important  in  such  states 
of  the  econoni}^,  whether  the  emansio  be  complete  or  partial.  At 
the  age  of  puberty,  some  menstrual  efforts  without  any  secretion 
are  often  manifested ;  in  some,  a  leucorrhoeal  discharge  ensues ; 
in  others,  it  is  pinkish  or  more  or  less  elaborated.  These  are 
82 


498         SEDATION    OF    THE    UTERUS. — A  MENO  RRHCE  A  . 

favorable  indications;  but  the  treatment  must  still  be  continued 
unremittingly. 

Asthenia  and  ansemia,  hoAvever,  are  not  necessarily  connected 
with  amenorrhoea,  in  some  cases,  as  from  premature  excitation  of 
the  nervous  system,  menstruation  may  be  established  or  even 
become  profuse.  This,  M.  Virey  well  calls  "precocious  menstrua- 
tion." The  precursory  and  attendant  indications  of  puberty  are 
absent ;  but,  there  is  a  full  development  of  the  genitals,  from  a 
premature  excitement  of  the  nervous  system,  the  mental,  moral, 
and  animal  sentiments,  passions,  etc.  This  is  nervous  irritation 
in  a  debilitated  system ;  it  increases  exhaustion  directly  by  the 
discharges,  and  indirectly  from  the  depression  which  succeeds 
excitement.  Hence,  the  sedation  or  debility  in  precocious  men- 
struation, demands  as  much  if  not  more,  than  in  ordinary  cases  of 
asthenia,  the  same  hygienic  and  invigorating  regimen. 

Moreover,  the  condition  of  the  patient  is  not  altered  by  the 
fact  that  the  catamenia,  although  once  established,  had,  from  any 
cause,  disappeared.  This  is  a  case  of  '■'■  suppression  of  the  menses,^^ 
as  termed  by  systematic  writers ;  but  in  no  essential  respect,  does 
it  differ  from  the  already  described  cases  of  emansio  mensium 
in  asthenic  individuals.  The  debility  may  be  so  great,  that  no 
secretion  occurs ;  but  in  other  cases  after  secretion  has  been  esta- 
blished, exhaustion  supervenes,  and  then  the  patient  is  reduced  to 
the  same  condition  as  if  the  menses  had  not  originally  appeared. 

In  all  such  cases  of  partial,  irregular  menstruation,  or  complete 
amenorrhoea,  great  hope  may  exist  that  the  patient,  if  favorably 
situated,  and  properly  treated,  may  recover. 

Organic  Diseases. — There  are  cases  where  either  originally 
as  a  cause,  or  secondarily  as  an  effect  of  these  cachectic  states, 
positive  inflammatory,  or  organic  disease  exists  in  some  tissue  or 
organ  of  the  economy. 

The  imperfect  digestion,  the  irritating  character  of  the  unas- 
similated  food,  the  acid  and  putrefactive  character  of  the  ingesta 
of  the  stomach  and  bowels,  the  bad,  illy  elaborated  state  of  the 
various  secretions  from  the  liver,  stomach,  pancreas,  bowels,  etc., 
arising  from  the  impure  state  of  the  blood,  as  well  as  from  the 
want  of  power  in  the  secreting  tissues;  all  prove  more  or  less 
irritating  to  the  mucous  membranes  of  the  alimentary  canal. 
Hence   gastritis,  enteritis,   and   colitis,   not  unfrequently  ensue, 


ORGANIC    DISEASES — RHEUMATISM    AND    GOUT.       499 

with  their  reflex  influences  on  the  oesophagus,  pharynx,  mouth, 
etc.,  aggravating  as  well  as  complicating  the  original  disturb- 
ances. Under  such  circumstances,  any  of  the  many  forms  of 
organic  chronic  disease  may  be  induced.  Irritations  often  remain 
fixed  on  particular  tissues  or  organs,  until  changes  of  structure, 
softening  of  the  tissues,  suppurations,  ulcerations,  etc.,  result  to 
the  destruction  of  the  organ  and  the  life  of  the  sufferers.  Thus 
tuberculous,  or  scrofulous  affections  of  the  brain,  lungs,  heart, 
liver,  intestines,  etc.,  arise.  Hence,  also,  may  result  albuminuria, 
Bright's  disease  of  the  kidneys,  or  even  uraemia,  which  some 
authors  have  regarded  not  always  as  the  consequence,  but  some- 
times as  the  cause  of  amenorrhoea.  Indeed,  there  may  be  induced 
any  variety  of  disease,  even  of  a  malignant  type,  followed  by  colli- 
quative diarrhoea,  vomitings,  and  dropsical  effusions  prior  to 
complete  prostration,  from  which  there  is  no  reaction.  Such 
cachexia  may  be  hereditary,  and  may  appear  at  or  soon  after 
birth,  during  childhood,  or  after  adolescence;  but,  in  all  cases,  it 
either  prevents  the  appearance  of  the  catamenia,  or  causes  its  dis- 
appearance. The  amenorrhoea  is  not  the  cause,  but  the  result ; 
and,  therefore,  should  never  be  treated  as  the  disease — ipse  mor- 
bus— but  as  a  secondary,  and  often  an  unimportant  symptom.  If, 
by  any  fortunate  circumstance,  the  chronic  disease  and  the 
asthenia  be  relieved,  then  the  uterine  discharge  may  ensue;  its 
appearance  may  indeed  be  hailed,  not  as  the  removal  of  the  cause, 
but  as  a  strong  indication  of  returning  health.  In  phthisis  pul- 
monalis,  all  are  familiar  with  the  gradual  disappearance  of  the 
menses,  as  the  organic  disease  becomes  more  and  more  decided, 
and  even  in  less  terrible  affections  of  the  pleura,  lungs,  liver,  etc., 
amenorrhoea  may  ensue.  Although  there  should  be  a  partial 
return  of  the  menses,  encouraging  the  patient  and  her  friends, 
yet,  in  all  instances,  the  treatment  ought  to  be  founded  on  the 
condition  of  the  diseased  organ  and  general  system,  and  not  on 
the  condition  of  the  uterus  and  its  appendages. 

Eheumatism  and  Gout. — Amenorrhoea  follows  also  in  the 
train  of  rheumatism,  gout,  cutaneous  and  other  metastatic  dis- 
eases. 

Dysmenorrhoea,  monorrhagia,  haemorrhagia,  and  other  forms 
of  uterine  irritation  have  been  already  mentioned  as  dependent 
on  the  translation  of  the  morbid  excitement  to  the  uterus.     The 


500        SEDATION    OF    THE    UTERUS. — AMEXORRHCEA. 

reverse  is  also  true.  The  translation  may  be  from  tlie  uterus  to 
other  tissues  or  organs — the  latter  being  in  a  state  of  irritation, 
the  former  of  sedation.  Hence,  occasionally  we  have  amenor- 
rhoea  either  under  the  denomination  of  emansio  mensium,  or  of 
suppressio  mensium. 

Case. — We  attended  a  very  interesting  young  lady,  of  eighteen 
years  of  age,  who  for  some  two  or  three  years  had  suffered 
severely  from  acute  rheumatism.  The  irritation  had  fixed  itself 
chiefly  in  the  right  hand  and  forearm,  producing  some  deformity 
of  the  hand,  from  which  she  never  fully  recovered.  She  had 
never  menstruated.  Her  rheumatic  complaints  were  relieved 
after  a  few  months;  the  catamenia  then  appeared.  She  after- 
wards married,  and  became  the  mother  of  children. 

The  same  result  from  metastasis  to  other  organs  may  also 
follow  after  the  appearance  of  the  menses.  There  is  also  a  close 
connection  between  amenorrhoea  and  some  of  the  varieties  of 
emtjjtive  and  cutaneous  diseases. 

The  TREATMENT  is  to  be  founded  on  these  pathological  facts, 
so.  that  the  usual  means,  by  diet,  medicine,  etc.,  are  requisite  for 
the  original  affection.  While  inordinate  irritation  is  moderated 
in  the  suffering  tissues,  measures  should  be  instituted  to  deter- 
mine nervous  and  vascular  excitement  once  more  to  the  uterine 
organs,  precisely  on  the  same  principle,  as,  when  gout  affects  the 
brain,  heart,  or  lungs,  "derivation"  should  be  made  to  the  sur- 
face of  the  body  and  to  the  extremities. 

In  acute  attacks  of  rheumatism,  gout,  etc.,  derivation  to  the 
pelvic  viscera  should  be  made  by  mild,  but  still  very  efficient 
measures ;  such  as  pediluvia,  hip-baths,  local  vapor-baths,  fomen- 
tations, poultices,  warm  vaginal  and  rectal  injections,  and  occa- 
sionally stimulating  enemata  of  senna,  aloes,  turpentine,  etc.,  to 
the  bowels. 

In  chronic  cases,  such  means  may  be  assisted  by  rubefacients, 
blisters  to  hypogastrium,  to  the  sacrum,  to  the  thighs,  etc.  In 
such  instances,  also,  resort  may  be  had  to  internal  remedies, 
especially  to  purgatives;  as  senna,  colocynth,  rhubarb,  aloes, 
which  have  their  chief  influence  on  the  large  intestines,  and  it  is 
supposed  sympathetically  on  the  uterus.  The  treatment  of  such 
chronic  cases  may  demand  the  employment  of  all  those  means 
which  are  supposed  to  have  a  direct  or  even  a  specific  influence 


RHEUMATISM,    FEVERS,    ETC.  501 

over  tbe  uterine  functions,  known  by  the  expression  Emmena- 
gogues,  wliicli  will  hereafter  be  noticed. 

Fevers  and  Phlegmasia. — A  suspension  of  uterine  secretion, 
partial  or  complete,  is  the  result  sometimes  of  acute  fevers  and  of 
the  phlegmasise.  In  the  former,  such  is  the  universal  disturbance 
of  the  economy,  that  perhaps  there  is  no  function  but  is  partially 
disturbed,  and  many  are  completely  suspended,  from  the  deficiency 
of  nervous  action,  from  congestions,  etc.  The  stomach,  liver,  and 
uterus  suffer  alike  in  this  prostration  of  their  peculiar  functions. 
In  the  same  manner,  in  the  phlegmasise  of  important  organs  there 
may  be  a  suspension  of  uterine  secretion,  or  transference  of  irri- 
tation to  the  affected  organ. 

In  all  such  vascular  disturbances,  amenorrhoea  is  a  secondary 
circumstance.  Every  practitioner  addresses  himself  almost  ex- 
clusively to  the  organic  disease,  and  looks  for  a  return  of  the 
menses  on  the  patient's  restoration  to  health.  Such  return  will 
generally  be  manifested ;  but  sometimes  the  injury  sustained  is 
more  permanent,  and  the  usual  course  of  derivative  means,  and 
perhaps  occasionally  of  emmenagogues,  may  be  demanded  to  re- 
lieve the  sedation  of  the  uterus. 

Nervous  Irritations. — In  other  cases  of  amenorrhoea  this 
transference  of  irritation  from  the  uterus  to  other  organs  involves 
not  chiefly,  as  in  the  last  mentioned  cases,  the  organic  life,  but 
mainly  the  nervous  system.  There  is  nervous  sedation  of  the 
uterus,  but  nervous  irritation  of  other  organs,  a  diminution  or 
suspension  of  the  menstrual  secretion,  but  increased  congestion 
and  consequent  effusion  or  secretion  from  other  tissues  or  organs. 

The  type  of  this  morbid  state  is  observed  in  the  physiological 
condition  of  the  uterus  and  mammas  during  lactation,  there  being 
sedation  of  the  uterus  and  suspension  of  its  secretion,  while  in  the 
mammee  there  is  excitement  with  an  abundant  excretion. 

The  causes  of  such  normal  and  abnormal  states  of  the  uterus 
and  mammae  are  entirely  obscure ;  but  that  such  conditions  do 
exist,  and  that  there  is  a  close  connection  with  the  nervous  sys- 
tem, there  can  be  little  doubt. 

It  seems  hardly  requisite  to  present  facts  confirmatory  of  the 
domain  of  the  cerebro-spinal  system  over  the  uterine  functions, 
especially  as  so  much  has  already  been  detailed  in  the  former 


502         SEDATIO?f    OF    THE    UTERUS. — A  MENOREHCE  A. 

parts  of  this  work.  Attention,  however,  may  be  fixed  on  the 
fact,  that  when  certain  peculiar  changes  occur  in  the  brain  and  its 
appendages,  there  follow  the  development  of  the  genital  organs, 
and  the  establishment  of  their  wonderful  functions  at  the  age  of 
puberty.  When,  however,  another  inscrutable  change  occurs  at 
the  climacteric  of  woman's  life ;  the  ovaries,  uterus,  and  mammae 
fall  into  a  state  of  sedation  and  of  atrophy.  Again,  there  is  a 
special  nervous  excitement  and  consequent  congestion  at  every 
menstrual  period,  in  the  non -parturient  and  healthy  female.  Dur- 
ing the  intervals  of  the  regular  periods,  the  menstrual  discharge  is 
often  re-excited  by  any  excitation  arising  from  the  influences  of 
the  mind,  of  the  emotions,  feelings,  and  sentiments.  The  essential 
influences  of  the  nervous  system  in  the  erections  and  congestions 
during  fecundation  are  universally  acknowledged.  Allusion  has 
already  been  made  to  the  sedation  of  the  uterus  and  its  functions 
b}^  the  depressing  influences  of  anxiety,  melancholy,  fear,  etc.  A 
young  lady  fell  down  a  flight  of  stairs  while  menstruating ;  there 
was  an  immediate  cessation  of  the  discharge,  which  did  not  return 
for  two  years.  During  lactation,  also,  there  is  a  suspension  of 
the  uterine  functions.  In  such  cases  the  mammse  are  the  irritable 
organs ;  the  mental  and  moral  emotions,  whether  exciting  or  de- 
pressing, then  influence  their  actions,  congestions,  and  secretions 
even  more,  apparently,  than  the  same  emotions,  under  other  cir- 
cumstances, affect  the  uterine  functions.  The  transient  thought 
of  her  bright  and  healthy  infant  will  instantaneously  augment  the 
turgescence  of  the  breasts  of  a  lactescent  mother,  and  her  supply 
of  nutriment ;  while  the  sickness  or  death  of  the  child  will  rapidly 
cause  their  collapse,  and  the  diminution,  vitiation,  and  arrest  of 
their  secretion. 

As,  in  health,  peculiar  conditions,  therefore,  of  the  nerves 
have  such  wonderful  influences  on  the  uterus,  surprise  need  not 
be  experienced,  if  morbid  states  of  the  nervous  system  produce 
disturbances  of  the  uterine  functions ;  although  the  true  nature 
of  these  peculiar  states  of  the  nerves  may  be,  in  no  degree,  under- 
stood. 

Thus  amenorrhoea  occasionally  occurs  in  girls  who  iare  appa- 
rently healthy.  The  phenomena  of  puberty  are  decided ;  the 
skeleton,  the  muscles,  the  organs  of  generation,  the  mammae,  the 
adipose  tissue,  are  all  well  developed,  under  the  influence  of 
good  rich  blood,  which  distends  the  capillaries,  and  gives  the 


NERVOUS    IRRITATION.  503 

ruddy  tinge  of  health  to  the  whole  surface.  The  brain  is  active  ; 
the  muscular,  mental,  and  moral  powers  are  all  indicative  of 
perfect  adolescence.  Nevertheless,  there  is  no  menstruation.  It 
is  a  case  of  emansio  mensium  in  a  strong  girl,  arising,  therefore, 
not  from  asthenia,  but  from  some  peculiar  state  of  the  nervous 
system ;  there  is  a  sedation,  that  is,  a  want  of  that  peculiar  excita- 
tion which  gives  origin  to  menstruation.  In  some  such  supposed 
cases,  there  may  be  an  absence  or  an  alteration  in  the  structure  of 
the  uterus  or  of  the  ovaries,  etc.,  or  an  obstruction  in  the  vagina, 
or  some  other  cause,  explanatory  of  the  non-appearance  of  the 
menses.  But  in  many  cases  no  such  cause  of  amenorrhoea  can  be 
detected,  and  indeed  does  not  exist;  for,  eventually,  the  menses 
appear  and  return  regularly. 

This  same  state  may  also  be  observed  in  cases  of  suppression 
of  the  menses,  from  any  accidental  cause,  as  mental  disturbances, 
exposure  to  cold,  etc.  The  menses  stop,  but  the  organic  life  con- 
tinues very  good.  The  cases  are  numerous  of  young  women 
whose  menses  have  thus  disappeared,  and  yet  they  have  enjoyed 
good  health  for  a  longer  or  shorter  time,  or  even  for  the  rest  of 
their  lives. 

In  these  cases  of  amenorrhoea,  where  the  irritation  is  located  in 
the  nervous  centres,  the  consequences  may  be  severe,  although 
seldom  dangerous.  The  symptoms  of  cerebro  spinal  irritation  are 
often  developed.  Usually  the  patient  appears  perfectly  well,  is 
cheerful,  happy,  and  actively  devoted  to  her  ordinary  pursuits, 
but  with  a  nervous  system  so  susceptible,  that  the  least  impression 
disturbs  it.  A  disagreeable  object,  an  unpleasant  odor,  a  transi- 
tory mental  or  moral  emotion,  will  sometimes  produce  sensations 
of  exhaustion,  giddiness,  languor,  and  even  complete  syncope ; 
and  if  the  cause  be  more  powerful,  as  fear,  joy,  auger,  or  severe 
pain  in  any  portion  of  the  body,  we  have  manifested  the  various 
forms  of  hysteria,  such  as  headaches,  a  sense  of  suffocation, 
globus  hystericus,  spasms,  and  convulsions.  Often  with  or  with- 
out severe  nervous  irritation,  there  is  more  or  less  congestion  of 
particular  organs,  followed  by  increased  excretions,  secretions, 
and,  it  may  be,  effusions  of  blood  from  the  nose,  lungs,  stomach, 
bowels,  etc.,  generally  to  the  partial  or  complete  relief  of  the 
symptoms. 

These  hysterical  phenomena  sometimes  vanish  speedily,  and 
the  ordinary  appearance  of  health  is  soon  manifested.     But  this 


504         SEDATION    OF    THE    UTERUS. — AMENORRHGEA. 

hysterical  state  may  continue  for  years,  with  varying  intensity ; 
however,  if  there  should  be  an  appearance  of  the  menses — that  is, 
if  the  proper  uterine  nervous  irritation  should  occur — there  is  a 
decided  relief;  the  catamenia  being  established,  the  patient  is 
better.  Nevertheless  the  relief,  even  then,  is  not  always  com- 
plete ;  hysterical  symptoms  often  continue,  probably  from  causes 
formerly  noticed  under  the  head  of  nervous  irritation. 

The  return  of  the  menses  is  often  partial ;  they  are  pallid,  or 
even  white,  and  then  afford  less  relief  to  the  economy. 

Such  patients  often  enjoy  excellent  health,  but  occasionally  in 
chronic  cases  they  lose  their  healthy  aspect,  and  assume  a  pallid 
and  sallow  condition  of  the  surface,  a  want  of  activity  and  excite- 
ment not  only  of  the  vascular  system,  but  of  the  thoughts  and 
feelings,  with  much  muscular  languor  and  weakness;  a  kind  of 
premature  senescence,  instead  of  the  ruddy  glow,  the  sprightliness 
and  buoyancy,  the  activity  and  hilarity  so  associated  with  our 
ideas  of  a  healthful  and  well-developed  girl.  When  the  absence 
of  the  menses  continues,  the  patient  may,  as  detailed  under  the 
first  and  second  of  these  pathological  states,  fall  gradually,  not 
merely  into  this  condition  of  general  sedation  or  premature  de- 
cline of  vital  actions,  but  into  the  positively  morbid  conditions 
arising  from  asthenia,  with  or  without  organic  disease. 

The  instances,  therefore,  of  failure  of  the  menses  in  girls  whose 
systems  are  well  developed,  and  whose  organic  health  is  excellent, 
seem  to  depend  on  some  peculiar  inscrutable  state  of  the  nervous 
system.  This  system  has,  as  we  have  seen,  a  predominating  in- 
fluence over  woman,  on  her  generative  system,  the  appearance  of 
the  menses  at  puberty,  and  the  disappearance  at  the  change  of 
life ;  hence,  it  may  safely  be  inferred  that  it  has  a  similar  influ- 
ence on  the  morbid  and  irregular  condition  of  this  function. 
When  a  peculiar  nervous  excitement  is  fixed  on  the  pelvic  viscera 
at  puberty,  the  menses  occur ;  when  this  excitement  is  deficient, 
they  do  not  appear,  or  appear  in  an  imperfect  state.  The  general 
cerebro-spinal  symptoms,  the  hysteria,  are  present,  therefore, 
frequently  when  there  is  no  menstrual  effort.  These  hysterical 
symptoms  may  be  partially  relieved  by  the  removal  of  the  excit- 
ing causes,  by  the  occurrence  of  secretions  from  the  skin,  bowels, 
and  the  kidneys,  or  by  the  establishment  of  the  catamenia;  but 
even  in  this  last  event,  the  relief  is  seldom  complete.  More  or 
less  nervous  irritation  often  remains  and  is  slowly  dissipated,  as 


HYSTERICAL    PHENOMENA.  505 

changes  in  the  nervous  system  occur  from  the  alterations  in  the 
modes  of  living,  the  influence  of  marriage,  gestation,  etc. 

The  same  state  of  things  prevails  in  cases  of  suppression  of 
the  menses.  There  will  be  found  the  same  condition  of  the 
general  nervous  and  vascular  systems,  whether  sthenic  or  asthenic 
or  cachectic. 

In  the  sanguine  temperament,  with  the  usual  hysteric  pheno- 
mena, there  will,  in  the  disappearance  as  in  the  failure  of  the 
menses,  be  evidences  of  plethora,  with  determinations  to  particu- 
lar tissues,  occasionally  followed  by  effusions  of  serous  or  bloody 
fluids,  or  actual  hemorrhage,  to  relieve  the  engorgements.  In 
the  more  chronic  cases,  where  there  is  less  plethora,  and  generally 
not  so  much  activity  and  strength,  the  hysterical  and  nervous 
symptoms  will  be  less  violent,  it  may  be,  and  the  evidences  of 
congestion  comparatively  trifling.  Still,  in  many  cases,  as  in  the 
non-appearance,  of  the  menses,  there  may  be  partial  congestions 
of  one  or  more  tissues,  followed  by  discharges  of  blood,  etc.,  at 
intervals  more  or  less  regular — "  vicarious, '  or  metastatic  men- 
struation"— but  these  afford  only  partial  relief  to  the  nervous 
symptoms.  There  may,  also,  be  an  incomplete  return  of  the 
menses,  the  discharge  being  imperfect  in  quantity  or  quality, 
sometimes  it  is  mere  leucorrhoea. 

In  a  few  cases  the  menses  may  return,  but  the  original  injury 
to  the  nervous  and  vascular  systems  may  not  be  obviated,  even 
for  a  long  time,  perhaps  not  until  other  influences  than  the  mere 
condition  of  the  menstrual  function  are  exerted  to  rectify  the 
economy. 

Cold. — Exposure  to  cold  is  another  common  cause  of  amenor- 
rhoea. 

The  modus  operandi  of  cold,  or  the  abstraction  of  caloric,  has 
already  been  alluded  to.  It  has  a  direct  sedative  influence,  first 
on  the  nerves,  and  secondly,  on  the  circulation  in  diminishing  its 
rapidity,  and  in  producing  passive  congestions  of  the  great  viscera 
of  the  head  and  body.  Also,  when  the  reaction  is  rapid  and  severe, 
apoplectic  congestion  may  be  induced,  or,  in  more  moderate  cases, 
inflammatory  or  febrile  diseases ;  although  in  most  instances,  of 
strong,  healthy  individuals,  where  the  degree  of  cold  has  not  been 
severe,  the  reaction  is  beneficial,  tonic,  and  even  stimulating  in  its 
influences.     Great  good  often  results,  therefore,  from  the  judicious 


506         SEDATION    OF    THE    UTERUS.--'AMEXORRH(E A. 

local  or  general  use  of  cold  air  or  cold  water.  Tlie  whole  sj'-stem 
is  invigorated,  and  particular  functions  stimulated  and  strengtli- 
ened.  A  good  appetite,  for  example,  and  a  good  digestion,  which 
imply  good  secretions  from  the  stomach,  pancreas,  liver,  etc.,  are 
induced.  The  same  is  true  as  regards  the  uterine  functions. 
Thousands  of  women,  especially  in  savage  life  and  among  the 
strong  and  laborious  in  civilized  countries,  plunge  into  the  river 
or  ocean,  even  when  the  menses  are  flowing,  not  merely  with 
impunity,  but  sometimes  with  advantage.  The  discharge  is  not 
checked,  but  may  even  become  more  profuse.  Such  hardy  persons 
will  for  hours  stand  in  damp  and  wet  places,  frequently  without 
any  protection  to  their  feet,  or  even  immerse  their  limbs  in  cold 
water,  during  the  catamenia,  with  perfect  impunity. 

Seldom,  however,  can  such  exposure  be  ventured  on  by  the 
delicate,  refined,  and  sensitive  child  of  civilization,  whose  physi- 
cal education  has  been  neglected,  and  whose  mental  and  moral 
sentiments  have  been  developed  at  the  expense  of  the  health  and 
strength  of  her  corporeal  system. 

In  such,  a  general  or  local  cold  bath,  standing  in  cold  and  wet 
places,  or  even  getting  the  shoes  or  stockings  accidentally  damp, 
may  cause  a  disappearance  of  the  menses  for  the  time,  and  occa- 
sionally prevent  their  return.  A  young  friend  and  patient  of 
much  talent  and  mental  culture,  anxious  to  be  present  at  an  eve- 
ning party,  immersed  her  feet  in  cold  spring  water  for  an  hour 
during  her  period ;  she  effectually  arrested  the  flow  for  the  time, 
but  so  greatly  injured  her  health,  that  she  remains  an  invalid, 
although  her  menses  afterwards  returned,  and  she  has  become  a 
wife  and  a  mother. 

The  reaction  which  ensues  after  exposure  to  cold  may  be  fol- 
lowed by  catarrhal  or  other  inflammatory  symptoms,  but  usually 
these  are  transitory.  In  some  cases  there  are  no  evidences  of 
fever  or  inflammation,  yet  certain  bad  effects  of  the  exposure 
remain.  These  are  manifested  not  simply  by  the  sedation  of  the 
uterine  functions,  but  of  other  organs — as  of  the  chylopoietic 
viscera,  in  the  loss  of  appetite,  the  imperfect  digestion,  the  torpor, 
of  the  liver,  of  the  bowels,  etc.  The  brain,  lungs,  and  heart,  with 
their  dependencies,  suffer  more  or  less,  with  the  consequent  de- 
terioration of  their  functions,  and  of  the  purity  and  richness  of 
the  blood,  etc.  A  premature  senescence  is  manifested,  almost  pre- 
cisely as  when  such  suppressions  are  caused  by  mental  and  moral 


COLD.  507 

impressions.  This  state  of  depression  from  cold  may  remain,  ap- 
parently stationary,  for  years,  the  patient  having  "feeble  health;" 
or,  under  unfavorable  circumstances,  and  when  additional  causes 
are  operative,  she  may  gradually  sink  into  a  complete  state  of 
asthenia  or  cachexia,  with  their  miserable  and  even  fatal  results — 
diseased  viscera,  dropsies,  etc.  In  many  instances,  partial  reac- 
tions of  the  nervous  system  occur,  showing  themselves  in  the 
from  of  headaches,  neuralgia,  or  other  varieties  of  nervous  irrita- 
tions, perhaps  with  partial  congestions  of  organs  or  tissues,  when 
effusions,  secretions,  and  hemorrhages — passive  or  active — "  vica- 
rious menstruation,"  may  follow. 


CONCLUSIONS. 

All  these  pathological  states  connected  with  amenorrhoea  are 
generally  regarded  simply  as  owing  to  the  arrest  of  the  men- 
strual flow,  and  therefore  to  re-establish  the  discharge  is,  to  the 
masses,  the  only  indication :  they  suppose  if  the  flow  be  absent, 
the  patient  is  sick;  if  it  be  excited,  the  patient  will  be  well. 

If  the  history  presented  be  true,  the  incorrectness  of  this 
opinion  is  evident.  The  suspension  of  the  menses  is  doubtless 
very  injurious;  it  is  an  arrest  of  an  excretion;  it  implies  the 
diminution  of  nervous  and  vascular  excitements  of  the  uterus,  a 
morbid  state  or  sometimes  a  want  of  a  proper  development  of  the 
ovarian  vesicles,  of  the  iiterus,  etc.,  and  probably  the  non-elimi- 
nation of  elements  of  a  noxious  character  from  the  blood,  and  the 
consequent  depravity  of  the  circulating  fluid.  All  this,  and  even 
more,'  may  be  true;  but,  the  mental  or  physical  phenomena  that 
caused  this  suppression  had  not  a  mere  local  effect  on  the  uterus 
and  its  appendages,  but  also  a  similar  influence  on  other  organs — • 
as  the  brain,  heart,  and  their  dependencies.  Hence  arises  the 
trouble  to  other  functions,  as  well  as  to  that  of  the  uterus ;  hence, 
the  want  of  proper  activity  of  other  organs;  hence,  congestions; 
hence  the  want  of  proper  elimination  of  noxious  elements  from 
the  lungs,  from  the  liver,  etc.,  as  well  as  from  the  uterus ;  and 
hence,  of  course,  the  general  deterioration  of  the  animal  economy. 

This  view  is  enforced  by  the  fact  that  the  restoration  of  the 
menstrual  function,  although  a  most  valuable  phenomenon  or 
sign  of  improvement,  does  not  necessarily  re-establish  the  health 


508         SEDATION    OF    THE    UTERUS. — AMENORRHCEA. 

of  the  patient.  The  catameuia,  more  or  less  elaborated,  may  flow, 
conception  may  ensue,  and  even  healthy  children  may  be  born, 
but  the  patient  may  continue  an  invalid  for  years. 
■  The  results  of  treatment  confirm  this  view.  "Whatever  confi- 
dence may  be  placed  in  specific  remedies — "  emmenagogues,"  as 
they  are  termed — to  re-excite  the  uterus,  almost  every  practi- 
tioner, elevated  above  the  level  of  the  empiric,  has  found  himself 
compelled  to  institute  a  general  course  of  treatment,  having  no 
direct,  but  merely  an  indirect  and  secondary  influence  upon  the 
pelvic  viscera. 

As,  therefore,  emansio  mensium  exists  from  certain  peculiar 
inscrutable  changes  of  the  system,  nervous  and  vascular,  although 
there  has  been  no  apparent  exciting  cause,  such  as  cold,  inflam- 
mations, mental  and  moral  influences ;  so,  also,  the  same  states 
exist  in  suppressio  mensium,  where  such  exciting  causes  have 
been  operative.  Practically  as  well  as  theoretically,  the  differ- 
ences, if  any,  are  not  appreciable.  Amenorrhoea,  in  all  cases,  is 
a  sign,  a  symptom,  therefore,  of  abnormal  states  of  the  uterus,  of 
the  ovaries,  of  the  secretory  organs,  or  of  the  general  nervous 
and  vascular  systems. 


DIAGNOSIS.  509 


CHAPTER    III. 

DIAGNOSIS  AND  TREATMENT  OF  SEDATION  OF  THE 

UTERUS. 

DIAGNOSIS. 

The  Diagnosis  of  araenorrhoea  is  of  course  generally  without 
difficulty.  Nevertheless,  in  some  cases,  much  knowledge  and 
experience  are  required  to  decide  the  nature  of  the  case. 

The  most  frequent  mistake  is  to  regard  cases  of  delayed  puberty 
as  a  diseased  state.  Mothers,  nurses,  and  empirics,  often  commit 
this  fundamental  error,  and  resort  to  the  so-called  emmenagogues, 
often  with  positive  injury.  Care  should  be  taken  to  examine 
strictly  as  to  the  developments  of  the  economy,  and  as  to  the 
symptoms  of  approaching  menstruation,  whether  any  indications 
of  uterine  irritation  have  been  manifested.  If  no  evidence  exists 
of  these  changes  and  efforts,  it  is  not  a  case  of  "failure  of  the 
menses,"  but  one  of  tardy  development. 

Again,  if  development  has  occurred,  but  no  discharge  has  fol- 
lowed, and  the  patient  enjoys  good  health,  it  is  possibly  merely  a 
state  of  tardy  menstruation^  which  demands  no  interference ;  or,  it 
may  possibly  be,  that  there  is  an  absence  or  at  least  an  atrophy 
of  the  ovaries  or  uterus,  or  of  both. 

If  all  the  symptoms  of  menstruation  have  occurred,  not  merely 
once,  but  several  times  without  any  evacuation,  a  careful  exami- 
nation will  be  requisite  to  determine  whether  there  be  no  ohstruc- 
tion  from  an  imperforate  hymen,  contractions  of  the  vagina,  or 
cervix  uteri.  Especially  are  such  examinations  demanded,  when 
the  abdomen  begins  to  swell,  and  the  moral  as  well  as  the  phy- 
sical character  of  the  maiden  is  involved  in  the  decision  of  her 
medical  attendant. 

The  diagnosis  between  amenorrhoea  and  pregnancy  is  generally 
easy,  after  the  fourth  month,  in  healthy  women;  but,  during  the 
first  four  months,  and  even  afterwards,  especially  when  complica- 


510  TREATMENT    OF    SEDATION    OP    THE    UTERUS. 

tions  from  obesity,  from  dropsical  or  other  collections  exist,  the 
diagnosis  is  often  exceedingly  difl&cult,  and  will  sometimes  tax  all 
the  powers  of  the  physician.  The  difficulty  is  often  increased, 
as  in  many  instances  the  patient  will  not,  or  cannot  offer  any 
essential  assistance.  She  throws  all  the  responsibility  upon  her 
physician. 

Ladies  often  deceive  themselves  and  their  attendants.  Anxious, 
when  married,  to  have  a  family,  they  usually  take  it  for  granted 
that  if  there  be  no  menstruation,  there  must  be  pregnancy ;  so  that 
not  merely  a  few  weeks,  but  perhaps  months  elapse,  before  their 
doubts  are  excited,  and  the  mistake  is  revealed.  Such  mistakes 
are  sometimes  made,  even  when  there  has  been  almost  every 
mouth  some  sanguineous  discharge.  We  have  known  a  delicate, 
emaciated  young  woman,  under  her  mother's  advice,  during  ten 
months  of  this  supposed  gestation,  make  all  the  usual  prepara- 
tions for  herself  and  child ;  of  course,  she  was  perfectly  amazed 
when  informed  of  her  error.  In  another  case,  a  delicate  married 
lady,  sustained  by  the  opinion  of  her  husband,  committed  the 
same  error,  although  she  had  been  the  mother  of  four  children. 
In  females  married  late  in  life,  where  cessation  of  the  catamenia 
occurs  not  very  long  after  marriage,  and  where  there  has  been 
an  enlargement  of  the  abdomen,  such  false  suppositions  are  not 
unfrequent.  The  diagnosis  is  the  more  difficult  when  there  is 
any  great  development  of  the  abdominal  tissues,  preventing  satis- 
factory external  examination.  The  physician  must  be  very  cau- 
tious in  venturing  to  destroy  hope,  and  to  pronounce  the  swelling 
of  the  abdomen  "  ventus  seu  adeps  et  prgeterea  nihil." 

Physicians  are  occasionally  called  to  cases  of  pregnancy  in  girls 
who,  unfortunately,  have  never  been  married.  They  insist  that 
they  have  an  obstruction,  and  nothing  else ;  and  very  universally 
they  deny  not  merely  the  existence,  but  the  possibility  of  preg- 
nancy. Such  cases  are  extremely  delicate,  involving  in  the  result 
of  his  examination  the  character,  perhaps  the  reputation  of  the 
physician,  as  well  as  that  of  his  patient.  No  decision  ought  to 
be  made  unless  four  months  are  supposed  to  have  elapsed ;  and 
even  after  quickening,  the  expression  of  opinion  should  be  giveri 
with  as  much  reserve  as  is  consistent  with  truth  and  justice.  We 
have  heard  women  deny  the  possibility  of  such  an  event,  even 
after  labor  had  actually  commenced. 

It  is  well  known  that  pregnancy  has  been  mistaken  for  dropsy; 


PROGNOSIS. — TREATMENT.  511 

and,  on  the  other  hand,  paracentesis  abdominis  has  been  per- 
formed where  there  was  no  peritoneal  effusion. 

Amenorrhoea,  coexisting  with  hypertrophy  of  the  uterus,  sim- 
ple or  complicated  with  tumors  of  the  uterus,  or  with  tumors  of 
the  ovaries,  or  of  the  mesenteric  glands,  requires  often  great  care 
to  distinguish  it  from  pregnancy. 

C((se. — A  young  lady  had  an  abdominal  swelling,  and  no  men- 
struation. A  most  experienced  physician,  in  a  neighboring  city, 
was  called  in  consultation,  and  pronounced  it  a  case  of  pregnancy. 
The  young  lady  and  her  friends,  of  high  position  and  religious 
character,  repelled  the  suggestion  with  virtuous  indignation. 
Subsequently,  a  post-mortem  examination  revealed  an  enormous 
collection  of  gelatinous  matter,  vindicating  the  character  of  the 
lady,  and  injuring  the  reputation  of  her  physician. 

In  all  cases,  the  greatest  caution  and  care  should  be  exercised 
when  abdominal  tumors  exist  in  conjunction  with  amenorrhoea, 
as  perhaps  there  are  few  practitioners  of  extensive  experience, 
who  have  not  cause  to  regret  that  they  trusted  too  much  to  a 
hasty  examination,  and  to  the  character  and  assurances  of  his 
patient,  in  making  a  diagnosis  of  such  delicate  and  complicated 
cases. 

Prognosis. — The  prognosis  in  amenorrhoea  must  be  necessarily 
very  uncertain,  depending,  as  the  history  now  given  shows,  on 
the  ever-varying  condition  of  the  tissues  and  organs  of  the  body, 
and  on  the  general  health.  It  can  merely  be  said,  that  if  the 
health  be  restored,  the  prognosis  is  favorable,  that  is,  if  the 
general  disease  be  cured,  this  symptom,  amenorrhoea,  will  usually 
disappear. 

TREATMENT. 

If  the  views  presented  be  correct,  there  is,  perhaps,  no  treat- 
ment for  amenorrhoea,  which  can  be  called  direct,  that  is,  having 
a  positive  immediate  influence  to  re-establish  the  flow  of  the 
menses ;  no  confidence  can,  therefore,  be  placed  in  specific  medi- 
cines for  this  purpose,  in  the  so-called  "  Emmenagogues."  The 
almost  universal  experience  of  the  profession  confirms  this  view. 
The  employment  of  such  specifics  is  a  last  resort,  a  kind  of  for- 
lorn hope  to  the  experienced  physician;  while  it  becomes  a  fruit- 


512    TREATMENT  OF  SEDATION  OF  THE  UTERUS. 

ful  source  of  deception  and  consequent  mischief  to  the  sufferer, 
and  of  profit  to  the  empiric,  who,  in  public  and  private,  lauds  his 
"infallible  remedy."  Nevertheless,  there  are  general  and  also 
local  measures  which  are  all  important  in  the  management  of  the 
various  pathological  states  connected  with  amenorrhoea. 

Eemoval  of  THE  Cause. — The  first  general  indication  is  the 
removal  of  the  cause,  so  far  as  this  is  still  operative,  or  to  pal- 
liate it,  if  not  remediable.  This  is  the  essential,  the  all-important 
principle  in^  the  management  of  amenorrhcea,  regarding,  as  we 
have  done,  the  non  secretory  state  of  the  uterus  as  a  sign  or  con- 
sequence of  various  unnatural  or  morbid  states  of  the  pelvic 
viscera,  and  of  other  organs. 

Asthenia. — In  all  cases,  therefore,  of  asthenia  where  there  is  a 
failure  or  suppression  of  the  menses,  partial  or  complete,  the 
whole  effort  of  the  judicious  practitioner,  addressing  himself  to 
the  mental  and  corporeal  being,  should  be  to  invigorate  the 
economy,  and  to  give  tone  to  the  nervous  and  vascular  systems 
by  all  the  direct  and  indirect  means  he  can  employ.  The  regu- 
lation of  the  exercise  of  the  mental  and  moral  powers,  the  incul- 
cation of  the  importance  of  suitable  food,  pure  air,  exercise, 
bathing,  and  all  other  indispensable  hygienic  measures,  are  the 
foundations  of  his  practice,  and  are  to  be  assisted  by  alteratives, 
tonics,  and  occasionally  by  stimulants. 

Organic  Disease's. — Where  this  asthenia  is  complicated  with 
organic  diseases,  the  latter  must,  of  course,  receive  sj)ecial  atten- 
tion, secundum  artem. 

Bhenmatism,  Gout,  etc. — Where  gout,  rheumatism,  or  other 
metastatic  diseases  coexist  with  amenorrhoea,  they  demand  pri- 
mary attention  for  their  removal  or  palliation,  while  suitable 
measures  are  employed  to  determine  the  nervous  and  vascular 
excitements  again  to  the  uterus  and  its  appendages. 

Fevers  and  Injlammations. — The  same  principle  should  regulate 
the  physician  in  all  the  febrile  and  inflammatory  complaints  of 
an  acute  or  active  character.  When  the  inflammation  is  located 
in  the  ovaries  or  the  uterus,  the  local  evacuants,  necessary  to 
affect  resolution,  act  on  the  principle  of  removing  the  cause, 
which,  in  this  case,  is  the  phlogosis. 

Mental  and  Moral  Disturbances;  Exposure  to  Cold,  d'c. — When 
amenorrhoea  exists  from  mental  or  moral  disturbances,  from  ex- 


REMOVAL    OF    THE    CAUSE.  613 

posure  to  cold,  or  other  causes  usually  transitory,  tlie  injury  sus- 
tained by  tlie  nervous  and  vascular  systems  often  remains  long 
after  the  exciting  cause  has  disappeared.     This  deserves  constant 
and  scientific  attention,  that  the  function  of  the  uterus  may  be  • 
resuscitated. 

All  these  truths  are  practically  acknowledged  by  any  regular 
practitioner,  who,  whatever  may  be  his  confidence  in  specifics, 
never  neglects  what  is  termed  general  treatment. 

Local  measures  are  often  important  when  there  is  organic  irri- 
tation, such  as  inflammatory  disturbances  of  the  pelvic 'viscera, 
and  also  in  cases  of  nervous  irritations  and  congestions.  They 
are  more  efficient,  if  any  indication  of  the  menstrual  nisus  be 
present. 

Cups  and  Leeches, — The  employment  of  cups  to  the  sacral 
region,  or  to  the  hypogastrium  ;  of  leeches  to  the  abdomen,  to  the 
groins,  to  the  upper  part  of  the  thighs,  to  the  pudendum,  to  the 
vagina,  and  to  the  uterus,  have  often  been  very  efiicient  in  reliev- 
ing excitement  and  congestion,  and  thus  promoting  secretion. 
There  are  but  few  who  have  not  found  such  practice  useful.  Two 
observations  may,  however,  be  made. 

First.  It  is  remarkable  that  the  relief,  afforded  by  the  artificial 
discharge  of  blood,  is  by  no  means  proportionate  to  that  which 
ensues  from  the  natural  secretion.  For  six  or  eight  ounces  of 
blood  really  do  not  relieve  a  patient  as  much  as  half  an  ounce  or 
an  ounce  of  menstrual  discharge. 

Second,  Judging  from  our  own  experience,  direct  loss  of  blood 
from  the  vagina  or  the  uterus  is  not  as  efficient  in  any  degree  as 
from  the  adjacent  external  tissues — "a  derivative  leeching,"  as  it 
has  been  termed.  Whether  this  comparative  inefficiency  of  the 
loss  of  blood  from  the  organ  involved  arises  from  the  mental 
and  physical  suffering  attendant,  more  or  less,  on  the  operation, 
efi'ected  by  means  of  a  speculum,  or  on  the  soreness  and  inflam- 
mation ensuing  from  the  leech-bites,  or  some  other  cause,  may 
not  be  clear ;  but,  in  many  instances,  the  irritation  has  been  but 
partially  relieved,  and  in  some  positively  augmented. 

Scarifications  to  the  neck  of  the  uterus  have  been  proposed ; 
but  these  also  require  the  use  of  a  speculum,  with  its  mental  and 
physical  objections ;  and  the  loss  of  blood  is  comparatively  trifling, 
while  the  subsequent  irritation  is  sometimes  considerable. 
33 


514    TREATMENT  OF  SEDATION  OF  THE  UTERUS. 

It  has  been  suggested  to  draw  blood  from  tlie  interior  of  the 
uterus  by  suction.  A  perforated  bent  tube,  resembling  a  silver 
catheter,  is  introduced  into  the  uterus,  and  to  the  other  extremity 
an  exhausting  apparatus  is  affixed.  Some  blood  can  doubtless  be 
obtained  in  this  way  from  the  delicate  and  vascular  lining  mem- 
brane of  the  uterus ;  but,  it  cannot  be  easily  imagined  how  such 
loss  will  counterbalance  the  pain  and  irritation  of  the  intra-uterine 
operation,  severe  even  in  the  passive  states  of  the  organ,  and,  of 
course,  much  more  so,  where  congestion  or  inflammation  exists. 

Fomentations,  etc. — Under  the  head  of  local  measures  in 
morbid  excitements  of  the  uterus,  with  no  secretion,  must  be 
placed  all  those  agents  termed  relaxing,  operating  by  promoting 
secretion — such  as  fomentations,  poultices,  warm  vaginal  and 
rectal  enemata.  They  are  very  soothing,  and  although  they 
determine  blood  to  the  part,  they  favor  secretion  and  relaxation 
— just  as  the  application  of  a  warm  poultice  to  an  external 
phlegmon. 

Cases  of  amenorrhoea  dependent  on  great  local  congestion,  or 
on  metritis  or  ovaritis,  are  comparatively  very  rare.  In  the  large 
majority  of  cases  there  is  sedation  in  every  sense — organic  as  well 
as  nervous — of  the  uterus  and  its  appendages,  demanding  in  many 
instances  remedies  of  a  different  character. 

Eevulsives  or  Derivatives. — These  all  act  by  determining 
excitement  from  a  tissue  or  tissues  where  it  is  inordinate,  to  those 
where  it  is  deficient.  They  equalize  excitement  so  far  as  they 
are  operative.  They  are  exceedingly  valuable,  and  perhaps  the 
most  reliable  in  the  estimation  of  the  modern  therapeutist.  If, 
therefore,  general  remedies,  whether  tonics  or  evacuants,  have  in 
any  degree  rectified  the  system,  if  local  inflammatory  or  organic 
changes  be  subdued,  and  especially  if  there  be  any  premonitions 
of  returning  uterine  action,  means  should  be  adopted  to  relieve 
the  sedation  of  the  nervous  and  vascular  tissues  of  the  womb. 
We  should  revulse  from  the  organs  unduly  excited,  to  the  uterus. 

These  measures  are  familiar  to  every  one,  but  some  of  the 
more  important  may  be  noticed,  as  many  have  been  relied  upon, 
in  popular  as  well  as  professional  practice,  as  if  specific — as  being 
really  emmenagogues — while  they  act  merely  as  revulsives. 

In  states,  therefore,  of  debility  or  sedation,  not  only  of  the 


LAXATIVES  —  EUBEFACIENTS.  515 

uterus,  but  of  other  organs,  great  good  is  obtained,  pro  tempore^ 
by  stimulating  diapboretic  measures,  to  be  resorted  to  especially 
at  the  expected  period.  They  not  only  determine  from  the  large 
congested  viscera  to  the  cutaneous  and  muQOus  surfaces ;  but 
they  favor  secretion.  Thus,  hot  baths^  general  and  local,  hot  drinhs^ 
hot  fomentations^  alcoholic  and  vegetable,  are  greatly  relied  upon. 
With  women,  and  even  physicians,  this  practice  having  been  often 
successful,  peculiar  specific  virtues  have  been  attributed  to  hot 
toddies  of  gin,  rum,  etc.,  to  hot  infusions  of  peppermint,  spearmint, 
catnip,  parsley,  pennyroyal,  madder,  tansy,  rosemary,  etc.  They 
all,  however,  are  advantageous  in  equalizing  the  circulation,  and 
facilitating  the  secretions  from  the  skin,  the  mucous  membranes, 
and  of  course  from  that  of  the  uterus.  Their  operation  is  greatly 
facilitated  by  those  medicines  termed  diaphoretics,  exhibited  with 
or  without  anodynes,  as  the  occasion  indicates. 

Laxatives,  but  not  cathartics  or  active  purgatives,  have  been 
always  much  depended  on.  They  act  perhaps  universally  as 
revulsives,  from  the  head,  lungs,  or  other  organs,  to  the  stomach, 
and  intestines.  They  not  only  relieve  constipation,  but  restore 
the  secretions  of  the  liver,  stomach,  intestines,  etc.  In  this  point 
of  view  they  are  more  efficient  when  combined  with  alteratives, 
in  minate  doses — as  of  mercury,  ipecacuanha,  antimony,  etc. 
Some  aperients,  such  as  sulphur,  rhubarb,  senna,  and  especially 
aloes,  act  mainly  on  the  large  intestines,  and  thence  sympatheti- 
cally on  the  uterus.  Hence,  aloes  and  some  other  laxatives  have 
been  universally  regarded  as  specifics  in  amenorrhoea. 

Stimulating  enemata  operate  also  as  revulsives  to  the  intestines 
and  secondarily  to  the  uterus.  They  are  really  useful  in  hasten- 
ing any  disposition  to  menstrual  secretion.  Enemata  of  senna, 
aloes,  and  turpentine,  have  had  much  effect,  and  are  often  re- 
garded as  specifics. 

Simple  or  stimulating  diuretics,  such  as  balsam  copaiba,  spirits 
of  turpentine,  tincture  of  cantharides,  sweet  spirits  of  nitre,  infu- 
sions of  juniper  berries,  gin,  etc.,  act  as  revulsives  to  the  kidneys 
and  the  pelvic  organs,  but  have  no  real  pretensions  to  peculiar 
influences  on  the  uterus. 

EuBEFACiENTS  are  not  to  be  neglected  when  premonitory 
symptoms  of  menstruation  are  present,  in  cases  of  amenorrhoea. 


516    TREATMEXT  OF  SEDATION  OF  THE  UTERUS. 

Altliougli  they  are  not  very  influential,  they  are  useful  in  assist- 
ing  other  revulsive  measures,  and  when  applied  in  the  neighbor- 
hood of  the  uterus,  assist  in  determining  excitement  to  its  tissues. 
Perhaps  the  most  important  are  cantharidal  blisters,  as  they  not 
only  favor  secretion,  but  have  much  direct  or  indirect  influence 
on  the  bladder,  the  rectum,  and  perhaps,  on  the  vulva,  uterus,  etc. 
They  may  be  applied  to  the  region  of  the  sacrum,  to  the  hypo- 
gastrium,  or  to  the  upper,  and  especially  to  the  inner  portion  of 
the  thighs. 

The  mammse  sympathize  so  directly  with  the  uterus,  that  prac- 
titioners have  hoped,  that  by  irritations  applied  to  these  glands, 
the  uterus  would  sympathetically  respond.  Dry  and  moist  heat, 
mustard  plasters,  blisters,  and  dry  and  wet  cups,  have  been  ap- 
plied to  the  breasts ;  and  stimulating  liniments  and  plasters  have 
been  employed,  but  with  very  doubtful  benefit. 

Any  success  attending  this  revulsive  treatment  in  the  re-esta- 
blishment of  uterine  action,  will  of  course  be  equally  efficient, 
where  vicarious  discharges  have  occurred  from  other  organs. 
As  the  natural  function  returns,  the  local  congestions  and  unna- 
tural discharges  from  other  organs  will  probably  disappear,  at 
least  they  will  demand  no  positive  treatment.  All  direct  attempts 
to  check  vicarious  menstruation,  from  the  nose,  ears,  stomach, 
rectum,  etc.,  are  exceedingly  dangerous,  as  the  irritation  and  con- 
gestion might  be  transferred  to  vital  viscera,  and  with  even  fatal 
results.  Should  it  unfortunately  happen  that  the  brain,  heart, 
or  lungs  be  the  seat  of  congestion,  with  or  without  seroid  or 
bloody  effusions,  the  treatment  should  be  chiefly  revulsive. 
Powerful  agents  of  this  character  may  occasionally  be  demanded, 
and,  if  the  congestion  of  the  brain,  heart,  or  lungs  assumes  a 
decided  apoplectic  character,  general  or  local  bleeding  may  be 
temporarily  employed,  as  in  cases  of  passive  congestion,  to  relieve 
the  oppressed  viscera,  while  the  bad  eftects  of  such  evacuations 
may  be  obviated  by  stimuli,  tonics,  nutritious  diet,  etc. 

Local  Stimuli  have  had  their  advocates,  and  in  the  form  of 
warm  water  or  vapor  directed  to  the  cervix  uteri,  have  already  ■ 
been  favorably  mentioned  as  adjuvants. 

Stimulating  washes,  particularly  the  aqua  ammonite,  in  the 
proportion  of  ten  drops  to  the  ounce  of  water  or  milk,  have  been 
recommended ;  but  the  success  has  been  but  trifling.    Injections 


LOCAL    STIMULI.  517 

of  ammonia  and  also  of  the  nitrate  of  silver  have  been  thrown 
into  the  cavity  of  the  uterus  with  reputed  success ;  but  certainly 
this  may  be  termed  rash  practice,  as  the  presence  of  the  instru- 
ment itself  gives  pain,  which  will  be  aggravated  by  the  injection 
of  even  simple  water,  and  much  more,  of  such  powerful  or  almost 
caustic  stimuli.  Irritations  are  excited  which  may  QOt  be  con- 
fined to  the  uterus,  but  extend  through  the  Fallopian  tubes  to 
the  peritonaeum,  with  probably  fatal  results.  Besides,  these  fluids 
may  possibly  at  once  pass  through  the  Fallopian  tubes,  and  thus 
directly  excite  peritonitis. 

Mechanical  stimuli  have  not  been  neglected.  The  occasional  pas- 
sage of  bougies,  or  the  metallic  uterine  sound  or  probe,  has  often 
been  employed.  More  lately,  in  cases  of  amenorrhoea,  the  intra- 
uterine pessary  has  been  recommended,  as  affording  a  permanent 
irritation.  But  few  successful  cases  have  been  reported  of  these 
measures.  Our  own  experience  is,  that  they  are  altogether  futile. 
We  have  frequently  been  called  upon  to  pass  the  probe  in  cases 
of  delayed  menstruation ;  and,  even  where  dysmenorrhcea  had  pre- 
viously existed,  there  has  not  been  any  hastening  of  the  menstrual 
discharge.  We  are  now  in  attendance  on  a  young  lady  who  has 
come  to  our  city,  for  relief,  if  possible,  from  a  dysmenorrhcea  of 
many  years'  duration.  "We  have  passed  the  uterine  sound  once 
before,  and  twice  since  the  time  for  the  regular  period — now 
delayed  for  two  weeks — and  jQt,  excepting  the  pain  of  the  opera- 
tion, and  a  slight  reddish  discharge  for  a  few  hours,  she  has  no 
indication  of  her  catamenia.  On  the  contrary,  she  feels  better 
than  usual,  and  has  not  as  yet  had  her  usual  premonitory 
symptoms. 

This  result  might,  a  priori^  have  been  anticipated  by  the  phy- 
siologist and  j)athologist.  Such  mechanical  operations  excite  pain 
and  contraction  of  the  uterus,  that  is,  "  nervous  or  animal  irrita- 
tion ;"  hence,  by  condensation  of  the  walls  of  the  uterus,  blood 
would  be  excluded,  not  invited  to  its  vessels.  The  trifling  san- 
guineous "  show,"  from  the  disturbance  of  the  delicate  epithelium 
of  the  lining  membrane,  is  no  proof  to  the  contrary.  Hence 
bougies,  as  formerly  mentioned,  are  occasionally  useful,  in  chronic 
menorrhagia,  and  therefore  would  probably  be  inefficient  in 
amenorrhoea. 

If  a  probe  or  an  intra-uterine  pessary  be  left  in  the  uterus, 
the  result  is  practically  the  same,  but  the  cause  entirely  different. 


518  TEEATMEXT    OF    SEDATIOX    OF    THE    UTERUS. 

The  continued  irritation  produces  organic  disturbance,  it  may  be 
inflammation ;  this  is  a  state  also  opposed  to  menstruation,  as  Ave 
have  already  seen,  metritis  as  well  as  ovaritis  is  a  cause  of  araen- 
orrhoea.  That  bloody  discharges  are  produced  by  intra-uterine 
pessaries,  there  can  be  no  doubt ;  but  hemorrhages  from  the  uterus 
are  not  the  catamenia  :  they  afford  but  partial  relief;  they  are  not 
the  results  of  that  peculiar  inscrutable  excitement  of  the  uterus, 
of  the  ovaries,  and  of  the  nerves,  necessary  for  the  formation  of  a 
true  menstrual  evacuation,  which  relieves  the  system,  depurates 
the  blood,  and  is  indicative  of  restored  health,  and  of  an  aptitude 
for  conception.  That  after  the  use  of  intra-uterine  pessaries,  the 
regular  return  may  sometimes  be  observed  is  very  probable ;  but 
this  ought,  we  think,  to  be  regarded  as  an  accident,  as  a  mere 
sequence,  not  an  effect.  This  possibility  ought  not  to  establish  a 
principle  or  to  sanction  the  use  of  a  disagreeable,  painful  instru- 
ment, which  is  liable,  as  formerly  mentioned,  to  very  serious,  if 
not  fatal  results. 

These  observations  are  applicable,  equallj^  if  not  more  forcibly, 
to  the  employment  of  suction  by  an  apparatus  already  mentioned, 
to  the  internal  surface  of  the  uterus.  What  effect  ought  reason- 
ably to  be  anticipated  from  the  abstraction  of  a  small  quantity  of 
blood  mechanically  from  the  internal  surface  of  the  uterus,  either 
as  a  substitute  for  the  important  menstrual  evacuation,  or,  as  an 
irritant  to  that  peculiar  nervous  excitement  and  active  congestion 
of  the  uterus,  ovaries,  and  all  the  pelvic  and  adjacent  viscera  re- 
quisite for  the  uterine  function  ?  The  mechanical  injury  from  the 
passage  of  the  intra-uterine  probe  in  this  instance  will  be  aggra- 
vated by  the  suction  power  emplo}- ed  on  the  delicate  mucous 
membrane  of  the  uterus, 

Emmenagogues  are  medicines  which  are  reported  to  have  a 
peculiar  physiological  influence  on  the  uterus  and  its  appendages, 
so  as  to  excite  them  to  perform  the  menstrual  actions  or  function. 

Are  there  such  remedies  ?  It  is  possible,  but  the  experience  of 
the  profession,  up  to  the  present  hour,  renders  it  exceedingly 
doubtful.  We  have  already  characterized  them  as  the  "forlorn 
hope"  of  the  scientific  ph3^sician,  who,  finding  all  his  science  and 
experience  inefficient,  falls  back  on  such  supposed  specifics,  and 
continues  his  warfare  with  some  lingering  expectation  of  an  even- 
tual victory. 


EMMEXAGOGUES.  519 

In  his  choice  of  such  measures,  the  practitioner  must  be  guided 
by  the  knowledge  of  the  actual  state  of  his  patient,  as  to  her 
general  system,  and  the  pelvic  viscera,  by  the  known  modus 
operandi  of  the  articles  suggested,  and  by  the  reputation  which 
may  have  been  accorded  to  them  by  good  authorities.  His  prac- 
tice must  be  somewhat  empirical  or  tentative,  but  still  under  the 
guidance  of  science. 

Many  of  the  supposed  specifics  have  already  been  noticed,  under 
the  head  of  tonics,  diuretics,  cathartics,  and  other  revulsives,  and 
the  list  could  easily  be  extended. 

Many  of  them  belong  to  the  class  of  alteratives.  Mercury,  so 
universally  useful  as  an  alterati\  e,  is  perhaps  as  important  in 
amenorrhoea,  as  any  single  remedy. 

Iodine  has  been  also  hailed  as  an  emmenagogue,  but  has  failed 
as  such ;  it  ma^'",  however,  be  advantageously  employed,  either 
by  itself  or  in  combination,  in  various  states  complicated  with 
amenorrhoea. 

Senerja  jjolygala  has  certainly  no  specific  effect,  although  strongly 
recommended  by  the  late  Professor  Chapman,  whose  practical 
acumen  was  almost  unrivalled. 

The  excellent  authority  of  Dewees  is  pledged  to  the  utility  of 
guaiacum,  especially  the  ammoniated  tincture  of  the  gum;  but  his 
successors  cannot  indorse  it.  "When  useful,  it  acts,  indeed,  as  a 
tonic  stimulating  diaphoretic, 

Sabina,  as  a  powder,  an  oil,  or  an  extract,  has  long  been 
regarded  as  having  a  special  influence  on  the  uterus,  and  has  been 
employed,  out  of  the  profession,  with  much  reputed  success,  not 
merely  as  an  emmenagogue,  but  as  an  excitant  of  the  uterus  to 
produce  contraction  during  pregnancy.  Nevertheless,  professional 
confidence  in  its  virtues  is  at  present  by  no  means  great. 

Ilellehorus,  in  sufficient  doses,  will  nauseate  and  purge,  and  this 
may  facilitate  uterine  excretion ;  but,  in  some  cases,  in  our  expe- 
rience as  well  as  in  that  of  other  practitioners,  it  appears  to  have 
favored  the  return  of  the  menses  when  no  perceptible  influence 
was  exerted  on  the  stomach  or  bowels. 

The  Secale  cornutum,  or  Urgot,  has  strangely  •  been  added,  by 
many,  to  the  list  of  emmenagogues.  Experience,  however,  has 
condemned  it,  and  theory  sanctions  the  sentence.  Under  peculiar 
circumstances,  it  has  a  wonderful  or  ,  specific  ■  influence  on  the 
uterine  nerves  and  muscles,  in  exciting  painful  contraction ;  but 


520    TREATMENT  OF  SEDATION  OF  THE  UTERUS. 

the  suggestion  is  very  crude,  that  hence  it  is  calculated  to  excite 
organic  actions,  congestion,  and  secretion.  In  the  former  case,  as 
a  peculiar  stimulant  to  the  uterine  nerves,  it  produces,  in  the  par- 
turient state,  contraction  of  the  muscular  fibres,  condensation  of 
the  substance  of  the  uterus,  and  diminution  therefore  of  the  size 
of  the  bloodvessels,  relieving  congestion  and  arresting  hemor- 
rhage ;  and,  in  the  unimpregnated  condition,  may  arrest  menor- 
rhagia  and  htemorrhagia  of  the  uterus,  in  cases  of  laxity  of  its 
tissues.  Of  course,  this  is  far  from  indicating  any  tendency  to 
promote  congestion  or  secretion  from  the  womb,  when  they  are 
deficient. 

Nux  vomica  and  Faba  St.  Ignatii,  with  their  various  preparations, 
have  been  proposed  as  emmenagogues.  As  tonics,  in  small  and 
repeated  doses,  they  are  very  useful ;  but  in  larger  doses  they  are 
dangerous ;  and,  since  they  operate  chiefly  on  the  nervous  and 
muscular  systems,  it  is  not  probable  that  experience  will  confirm 
the  suggestion,  that  they  have  specific  influence  on  the  organic 
actions  of  the  uterus;  at  least,  there  is  as  yet  no  general  testi- 
mony in  their  favor. 

Extract  of  the  Chenopodium  olidum  has  been  lately  recom- 
mended; the  Lauro-cerasus,  as  a  strong  decoction,  and,  indeed, 
many  other  articles  at  present  attract  attention,  some  of  which 
may  possibly  prove  successful  as  adjuvants,  under  the  direction 
of  the  enlightened  physician. 

Matrimony  has  been  recommended  in  amenorrhoea.  The  sexual 
excitements  have  doubtless  the  most  direct  influence  on  the  deve- 
lopment of  the  ovaries  and  the  uterus,  and  the  establishment  of 
their  functions.  They  may  give  origin,  as  formerly  mentioned, 
even  to  precocious  menstruation;  they  thus  confirm  the  argument 
as  to  a  controlling,  if  not  an  original,  influence  of  the  nervous 
system  over  the  functions  of  generation.  The  excitement,  there- 
fore, of  these  feelings  by  marriage,  and  the  additional  specific 
stimulus  of  the  semen  masculinum,  promote,  in  favorable  cases, 
the  catamenial  function.  Girls,  thin,  pallid,  and  with  but  few  of 
the  signs  of  womanhood  at  the  time  of  marriage,  often  develop 
very  rapidly  after  its  consummation  ;  the  nervous  system  and  the 
organic  life  are  equally  excited,  the  blood  becoming  richer  and 
nutrition  more  active,  even  when  no  conception  has  ensued.  In 
such  cases,  partial  or  complete  amenorrhoea  often  disappears,  and 
hopes  of  maternity  may  be  entertained. 


EMMENAGOGUES.  521 

Nevertlieless,  great  caution  sTiould  be  exercised  by  a  physician 
in  giving  sanction  to  matrimony  in  cases  of  amenorrh(jea,  there 
are  so  many  ethical,  and  legal,  as  well  as  physical  questions 
involved.  His  approbation  should  always  be  withheld,  unless 
he  is  satisfied  that  there  be  no  deficiency  of  the  ovaries  or  uterus, 
no  fixed  organic  disease,  and  no  incurable  mal-condition  of  the 
patient's  general  system  or  of  any  special  organ.  He  should  be 
convinced  that  it  is  a  mere  uncomplicated  state  of  sedation  of  the 
uterine  tissues. 

Electricity^  galvanism^  electro- galvanism.,  and  electro-magnetism, 
have,  in  succession,  been  suggested  as  important  therapeutical 
agents,  in  various  forms  of  disease,  especially  in  those  dependent 
on  the  nervous  system.  Fashion  has,  unfortunately,  had  its 
influence  in  the  scientific  as  well  as  in  the  gay  world.  After  the 
discovery  of  galvanism,  in  1786,  and  especially  of  the  Voltaic 
pile,  in  1800,  great  expectations  were  entertained  of  their  thera- 
peutical effects,  but  these  were  found  to  be  illusory. 

In  1825,  these  hopes  were  revived,  by  the  suggestion  of  em- 
ploying them  in  conjunction  with  acupuncture,  so  that  the  course 
of  the  electric  or  galvanic  influence  could  be  accurately  directed, 
or  localized.  This  was  also  attempted  by  denuding  two  separate 
portions  of  the  surface  of  the  body,  to  each  of  which  plates  were 
affixed,  connected  with  the  opposite  poles  of  a  battery.  Nume- 
rous as  were  the  experiments  made  in  this  city,  and  elsewhere, 
with  bright  anticipations  and  reputed  success,  the  practice  soon 
fell  into  disuse. 

During  the  last  few  years,  the  hopes  of  the  learned  and  the 
enthusiastic  have  been  resuscitated,  especially  since  the  discovery, 
by  Faraday,  of  "electricity  by  induction-currents,"  in  1831,  and 
the  suggestion,  by  Duchenne,  that  the  physiological  influences  of 
direct  electricity  and  that  by  induction  are  diff*erent.  Dr.  Du- 
chenne has  ingeniously  arranged  an  apparatus  to  localize  the 
influence  of  this  inductive  electricity,  and  to  direct  it  upon  an 
organ  or  tissue  involved.  Some  reports  are  very  favorable,  and 
great  attention  is  now  paid  by  regular  and  irregular  practitioners 
to  this  subject,  especially  in  the  treatment  of  cerebro-spinal  dis- 
eases, such  as  neuralgia,  paralysis,  etc.  Analogous  effects  have 
been  anticipated,  perhaps  too  readily,  as  regards  organic  life,  its 
actions  and  functions;  but,  as  yet,  there  have  been  no  decided 


622    TKEATMENT  OF  SEDATION  OF  THE  UTERUS. 

results.  Inflammatory  affections  of  the  skin,  and  of  tlie  mucous 
membranes,  have  been  induced  by  this  agent,  as  well  as  an 
increased  flow  of  saliva  and  other  secretions ;  but  how  far  thera- 
peutical advantages  may  result  in  organic  diseases,  is  very 
doubtful. 

As  an  emmenagogue,  electricity  has  been  recommended  for 
very  many  years,  but,  almost  universally,  without  decided  suc- 
cess. It  is  now  again  brought  prominently  before  the  profession 
under  the  form  of  "  Faradization,"  or  "  electricity  by  induction- 
currents,"  by  means  of  Duchenne's  and  other  apparatus,  for  locali- 
zation. The  results  are  yet  to  be  determined ;  one  practitioner, 
M.  Becquerel,  declaring,  after  repeated  trials,  that  it  uniformly 
failed.  Another,  Dr.  Althaus,  states,  that  in  twenty-four  cases  of 
amenorrhoea,  twenty  were  cured  by  this  means. 

Another  mode  of  employing  galvanism,  which  ingenuity  has 
suggested,  is  by  the  galvanic  pessary.  Upwards  of  twenty  years 
ago,  Dr.  Rose,  formerly  a  regular  physician  in  this  city,  employed 
a  vaginal  flat  disk  pessary,  with  the  upper  or  uterine  surface 
made  of  silver,  and  the  loAver  of  zinc,  but  probably  with  no  suc- 
cess, as  no  favorable  reports  have  been  given  of  its  influence. 

Dr.  Simpson  has  suggested  that  his  intra-uterine  pessary,  when 
constructed  with  the  style  or  uterine  portion  of  zinc,  and  the 
vaginal  portion  of  copper,  will  be  beneficial  in  amenorrhoea ;  and 
cases  are  given  by  himself  and  others  of  success  from  their 
employment.  The  stem  of  this  pessary  is  sometimes  made  of 
zinc  one-half,  and  copper  the  remainder ;  or,  as  Dr.  Noeggeratli 
has  advised,  making  two  equal  and  parallel  pieces  of  copper  and 
zinc.  Dr.  T.  Gaillard  Thomas  proposes,  in  order  to  give  some 
elasticity  to  the  stem,  that  it  should  be  made  of  alternate  beads 
of  copper  and  zinc,  strung  on  a  copper  wire,  secured  at  each 
extremity.  We  have  already  noticed  the  dangers  attending  the 
use  of  these  intra-uterine  supports,  in  their  mechanical  effects  on 
the  tissues  of  the  uterus ;  and  such  influences  will  probably  not 
be  lessened  by  the  decomposition  of  such  metals  as  zinc  and 
copper,  under  any  galvanic  process,  which  might  be  induced  by 
the  fluids  of  the  uterus  or  vagina.  The  question  also  is  in  abey- 
ance whether  the  bloody  discharge,  which  may  result,  is  a  pure 
hemorrhage  from  physical  or  galvanic  excitement,  or  a  proper 
menstrual  excretion. 


GENERAL    REMARKS.  523 

We  will  venture  the  following  general  conclusions,  and  express 
a  few  cautions  on  the  subject  of  Electricity  in  its  various  forms. 

First.  No  specific  or  peculiar  virtues  are  to  be  expected  from 
it  as  an  Emmenagogue.  It  is  a  mere  stimulus  at  best,  and  should 
be  placed  among  the  class  of  local  stimuli. 

Second.  Its  effects  on  organic  actions  are  trifling,  uncertain, 
and  very  generally  indirect,  and  of  course  not  reliable. 

Third.  In  cases  of  neuralgia,  spasms,  paralysis,  etc.,  it  may 
sometimes  prove  advantageous,  but  merely  in  those  instances 
where  the  general  or  local  irritation  has,  spontaneously  or  by 
therapeutical  means,  been  entirely  relieved,  and  a  simple  stimu- 
lus is  demanded. 

Fourth.  Much  science  and  judgment  are  required  to  regulate 
the  proper  direction  of  its  influence,  as  well  as  the  choice  of  the 
kind  of  electricity,  direct  or  indirect,  which  the  peculiarities  of 
the  case  demand ;  and,  especially,  it  is  necessary  to  control  the 
intensity  of  the  current.  Not  only  spasms  and  convulsions  have 
resulted  from  injudicious  employment  of  electricity ;  but,  in  sen- 
sitive women,  the  whole  nervous  system  has  remained  morbidly 
irritable  for  many  years  after  its  application. 


GENERAL  REMARKS. 

From  the  history  of  amenorrhoea,  it  is  manifest  that  the  patient 
should  be  constantly  under  the  supervision  of  the  practitioner. 
During  the  supposed  intervals  of  the  menstrual  nisus,  every  effort 
must  be  made  to  rectify  the  system,  and  to  relieve  local  diseases, 
so  as  to  favor  the  developments  and  functions  of  the  whole 
economy.  When  the  return  of  the  period  is  expected,  the  cir- 
culation must  be  determined  to  the  pelvic  viscera,  as  much  as 
practicable,  by  equalizing  the  general  excitement ;  by  promoting 
secretion  from  the  cutaneous  and  mucous  membranes,  univer- 
sally ;  by  revulsive  remedies,  internal  and  external ;  by  direct 
stimuli  to  the  uterus;  and,  sometimes,  by  the  employment  of 
medicines,  supposed  to  act  specifically  on  the  uterine  function. 

The  scientific  and  judicious  physician  will  know  how  to  assist 
his  hygienic  by  his  medicinal  measures ;  how  to  combine  laxa- 
tives, alteratives,  tonics,  stimuli,  and  specifics,  so  as  to  facilitate 


52-4    TREATMENT  OF  SEDATION  OF  THE  UTERUS. 

tlie  establishment  of  tlie  general  health,  and,  secondarily,  the  de- 
velopment and  secretions  of  all  the  organs  of  the  economy.  Dis- 
appointment must,  however,  often  ensue,  as  the  causes  of  amenor- 
rhoea  are  frequently  irremovable ;  but,  in  other  cases,  he  may 
anticipate  as  much  success  as  in  the  treatment  of  other  functional 
diseases. 


INDEX. 


A. 


Abdominal    operation    for    excision    of 
uterine  tumors,  4(j0 
tumors,  difficulty  of  diagnosis,  462 
Abscess  of  uterus,  140 
Amenorrlioea,  description  of,  491 
diagnosis  of,  509 
prognosis  of,  511 
treatment  of,  511 
Amputation  of  cervix  uteri,  450 
Ansemia,  definition  of,  93 
Anteflexion  of  the  uterus,  description  of, 
334 
treatment  of,  436 
Anteversion  of  uterus,  description  of,  332 
diagram  of,  333 
treatment  of,  435 
with  flexion,  334 
diagram  of,  333 
treatment  of,  436 
Aphonia,   reflex    influence   of    irritable 

uterus,  186 
Asthenia,  cause  of  amenorrlioea,  496 
Axes  of  body  and  pelvis,  diagram  of,  316 


B. 


Bandages,  treatment  of  displacements  of 

uterus,  377 
Baths,  treatment  of  irritable  uterus,  267 
Bladder,  hernia  of,  440,  442 

irritable,  211 
Bougies,  treatment  of  dysmenorrhoea,  285 

treatment  of  menorrhagia,  295 
"  Bow"  pessary,  420 
Broad  ligaments  of  uterus,  322 
"  Butterfly  pessary,"  396 


C. 


Case  of  a  mother  inclined  to  destroy  her 

children,  178 
of  amenorrhcea  from  a  fall,  502 
of  an  overtaxed  clergyman,  270 
of  anteflexion  of   the  iiterus  com* 

plicated  with  a  tumor,  361 


Case  of  atresia  of  the  vagina  with  dig- 
jilacement  of  the  uterus,  321 

of  bad  temper  due  to  uterine  irri- 
tation, 177 

of  caries  of  the  sacrum,  310 

of  convulsions  from  uterine  irrita- 
tion, 183 

of  convulsions  when  a  foot  was 
lifted,  yet  the  patient  could  move 
about  the  room,  272 

of  convulsive  movement  of  tlie  arm 
from  uterine  irritation,  182 

of  cystocele  and  rectocele  existing 
together,  441 

of  diarrhoea,  acting  as  a  substitute 
for  the  catamenia,  203 
complicating  endometritis  and 

irritable  uterus,  203 
from  uterine  irritation,  203 

of  dysmenorrhoea,  uterine  sound 
employed,  menses  delayed,  517 

of  dysuria  from  a  retroverted  ute- 
rus, 306 
with  a  pulsatile  pain,  212 

of  gangrenous  chancre  of  the  penis, 
248 

of  hernia  of  the  bladder,  442 

of  hysteria  from  a  diseased  knee- 
joint,  352 

of  hysteric  convulsions  which  had 
been  treated  for  inflammation  of 
the  brain,  etc.,  237 

of  imperforate  hymen,  495 

of  irritability  of  the  uterus  after 
inflammation,  291 

of  irritable  ovary,  468 

of  irritable  rectum  treated  for  fis- 
sure of  the  anus,  207 

of  irritable  uterus,  with  great  lan- 
guor and  no  pain,  171 

of  irritation  of  the  anterior  crural 
nerve,  222 

of  loss  of  amiability  due  to  uterine 
irritation,  177 

of  membrane  from  the  uterus,  125, 
127 
from  the  vagina,  125 

of  membranous  dysmeuorrhosa,  126 


526 


INDEX. 


Case  of  nervous  irritation  relieved  while 
inflammation  still  existed,  155 

of  ovarian  dropsy,  479 

of  partial  retroversion,  362 

of  peculiar  cough,  185 

of  "phthisis  incipiens"  complicated 
by  prolapsus  of  the  uterus,  299 

of  precocity,  being  injurious,  257 

of  retention  of  urine  in  irritable 
bladder  and  urethra,  212 

of  retroflexed  uterus  continuing 
while  a  large  fiat  ring  was  in  po- 
sition, 401 

of  retroversion  of  the  uterus  with 
peculiar  sounds,  438  -r 

of  retroversion  treated  for  "  spinal 
neuralgia,"  347  — 

of  rheumatism  causing  amenorrhoca, 
500 

of  salivation  in  the  treatment  of 
irritable  uterus,  247 

of  severe  symptoms  in  a  nervous 
temperament  from  a  slight  pro- 
lapsus, 229 

of  simulative  apoplexy  176 

of  spasm  of  the  pharynx,  183 

of  spectral  illusions,  178 

of  successive  pains  in  various  parts 
of  the  body  from  pressure  on  the 
sacral  nerves,  430 

of  torpor  of  the  bowels  in  attacks  of 
menorrhagia,  196 

of  tympanites  from  a  prolapsus 
uteri,  195 

of  uterine  tumor  giving  rise  to 
symptoms  of  hepatitis,  173 

of  uterine  tumors,  452 

of  vicarious  menstruation,  203 
Cases  of  abdominal  tumors,  difficulty  of 
diagnosis  in,  462,  463 

of  absence  of  the  uterus,  494 

of  alleged  ulcer  in  an  irritable  ute- 
rus due  to  retroversion,  136 
during  the  seventh  mouth   of 
pregnancy,  135 

of  amenorrhcea  mistaken  for  preg- 
nancy, 510,  511 

of  cough  caused  by  pressure  from 
a  pessary,  186 

of  exhaustion  upon  speaking,  184 

of  intra-uteriue  pessaries  employed, 
409 

of  irregular  development  of  the 
glandular  structure  of  the  breast, 
188 

of  irritable  lymphatic  glands,  219, 
220 

of  irritable  rectum  with  spasm,  207 

of  irritation  of  the  bladder,  212 

of  irritation  of  the  pelvic  nerves,  309 

of  neuralgic  pain  relieved  by  pres- 
sure, 381 


Cases  of  ovarian  tumors,  218,  219,  469 
of  pain  in  the  top  of  the  head,  etc., 

on  removing  a  pessary,  430 
of   prostration  from  general  bleed- 
ing in  the  treatment  of  irritable 
uterus,  246 
of    "  utero-abdominal    supporters'' 
worn  for  retroversion  of  the  ute- 
rus, 381 
Cauterization,  treatment  of  irritable  ute- 
rus, 248 
Cellulitis,  pelvic,  63   . 
Cephalalgia,  symptom  of  irritable  ute- 
rus, 174 
Cerebral  irritation,  symptom  of  irritable 

uterus,  169 
Cerebro-spinal  irritations,  symptoms  of 

irritable  uterus,  168 
Cervico-metritis,  137 
Cervix  uteri,  elongation  of,  450 
hypertrophy  of,  137 
strictures  of,  138 
ulcers  of,  134 
Chlorosis,  492 

Climate,  cause  of  irritable  diseases,  228 
Closed  lever  pessary,  description  of,  419 
diagrams  of,  415 
introduction  of,  425 
removal  of,  426 
with  the  small  curve  before — in 

position,  421 
with  the  small  curve  behind — 
in  position,  421 
Cold,  cause  of  irritable  diseases,  233 
Colpeurynter,  as  a  uterine  elevator,  455 
Complications  of  displacements  of  ute- 
rus, treatment  of,  447 
of  irritable  uterus,  treatment  of,  284 
Congestion,  active,  77 

cause  of  irritable  diseases,  230 

definition  of,  76 

opinion  of  authors,  37 

passive,  76,  485 

symptom  of  irritable  uterus,  113 

of  uterus,  37,  113 

treatment  of,  244 
Congestive  dysmenorrhoja,  122 
Constipation,  reflex  influence  of  kritable 

uterus,  196 
Corporeal  endometritis,  139 
hypertrophy,  140 
metritis,  140 
Coughs,  reflex  influence  of  irritable  ute- 
rus, 185 
Cystocele,  440 


D. 


Dewees'  pessary,  393 
Diabetes  serosa,  reflex  influence  of  irri- 
table uterus,  199 


INDEX. 


527 


Diagram  of  anteversion  of  the  uterus, 
333 
with  flexion,  333 
of  axes  of  the  body  and  pelvis,  316 
of  closed  lever  pessary,  415 

with  the  small  curve  before — 

in  position,  421 
with  the  small  curve  behind — 
in  position,  421 
of  flat  ring — in  position,  400 
of  interrupted  ring  pessary,  415 
of  introduction  of  open  lever   pes- 
sary, 423 
of  lever  for  the  removal  of  globular 

pessaries,  etc.,  393 
of  modified  intra-uteriue  pessary — 

in  position,  411 
of  natural   position   of    the  pelvic 

viscera,  317 
of  open  lever  pessary,  415 

— in  position,  416 
of  partial   retroversion  of  the  ute- 
rus, 335 
with  flexion,  337 
of  pelvic  nerves,  315 
of  posterior  view  of  the  uterus  and 

its  ligaments,  322 
of  procidentia  of  the  uterus,  338 
of  prolapsus  of  the  uterus,  331 

with  flexion,  331 
of  removal  of  open  lever  pessary, 

425 
of  retroversion  of  the  uterus,  335 

with  flexion,  337 
of  side  view  of  closed  lever  pessary, 

415 
of  Simpson's  intra-uterine  pessary, 

modified,  415 
of  uterine  sound  or  probe,  447 
of  varieties  of  open  lever  pessary,  415 
of  view  of  the  uterus  and  its  liga- 
ments  in   the    direction    of    tlie 
axis  of  the  superior  strait.  323 
Digital  vaginal  examinations,  112 
Diseases,  irritable,  69 
neurotic,  71 
of  irritation,  67 
of  sedation,  481 
Displacements  of  ovaries,  diagnosis  of, 
464 
treatment  of,  478 
of  uterus,  313 
causes,  339 
diagnosis,  352 
prognosis,  365 
symptoms,  346 
treatment  of,  367 
treatment  of  complications  of, 
447 
of  vagina,  440 
Diuresis,  reflex    influence    of    irritable 
uterus,  199 


Dropsy  of  the  ovaries,  478 
Dysmenorrhoea,  congestive,  122 

mechanical,  123 

membranous,  126 

pessaries  in  the  treatment  of,  287 

symptom  of  irritable  uterus,  109 

treatment  of,  284 


E. 


Ectropion  of  os  uteri,  137 

Electricity,  treatment   of    amenorrhoea, 

521 
Electro-galvanism,  treatment  of  amenor- 
rhoea, 521 
Electro-magnetism,  treatment  of  amen- 
orrhoea, 521 
"  Emansio  mensium,"  description  of,  493 
Emmenagogues,   treatment   of    amenor- 
rhoea, 518 
Endometritis,  cervical,  133 
corporeal,  139 

pessaries  in  the  treatment  of,  297 
symptoms  of,  141 
treatment  of,  157,  297 
Engorgement,  definition  of,  76 

opinion  of  authors,  37 
Enlargements  of  lymphatic  glands,  477 
of  ovaries,  diagnosis  of,  464 
symptoms  of,  215 
treatment  of,  478 
of  uterus,  treatment  of,  449 
Examinations,  vaginal,  111 
Excision  of  tumors  of  uterus,  456 
Excitability,  definition  of,  69 
Excitants,  definition  of,  69 
Excitation,  definition  of,  69 
Excitement,  definition  of,  69 
Exercise  and  rest,  treatment  of  irritable 
uterus,  270 


Faradization,  treatment  of  amenorrhona, 
522 

Fascia  of  the  pelvis,  326 

Flat  ring  in  position,  diagram  of,  400 

Flatulence,  reflex  influence  of  irritable 
uterus,  191 

Flexion  of  uterus,  332,  334,  336 
treatment  of,  447 

Fluor  albus,  symptom  of  irritable  ute- 
rus, 118 

Food,  treatment  of  irritable  uterus,  263 


Galvanism,  treatment   of  amenorrhosa, 
521 


528 


IXDEX. 


Gastrotomy,   treatment   of  ovarian   tu- 
mors, 478 
ti-eatmeut  of  uterine  tumors,  460 

Gout,  cause  of  amenorrhoea,  499 
cause  of  irritable  diseases,  228 
of  uterus,  treatment  of,  253 


H. 


Hsemorrhagia,  symptom  of  irritable  ute- 
rus, 117 
Hard  India-rubber,  material  for   pessa- 
ries, 390 
Hemorrhage,  witli  displacement  of  ute- 
rus, 448 
Hernia  of  bladder,  440,  442 

of  rectum,  440 
"Horse-slioe"  pessary,  414 
Hymen,  imperforate,  495 
Hypersestliesia  of  the  skin,  symptom  of 

irritable  uterus,  173 
Hypertrophy  corporeal,  51,  140 
of  the  cervix,  137 

of  uterus,  symptom  of  irritable  ute- 
rus, 115 
treatment  of,  164,  250,  367,  449 
opinion  of  authors,  51 
Hysteralgia,  meaning  of,  101 
Hysteria,  meaning  of,  168 
Hysterotome,  treatment    of    dysmenor- 
rhoea,  285 
treatment  of  tumors  of  uterus,  457 


I. 


Induration  of  uterus,  treatment  of,  251 
Inflammation,  cause  of  irritable  diseases, 
230 
followed  by  irritability,  151 
of  ovaries,  61 
of  uterus,  57,  130 

treatment  of,  156,  244,  296 
Interrupted  ring  pessary,  diagram  of,  415 
Intestines,  relation  to  uterus,  327 
lutra-uterine  pessaries,  402 

treatment  of  amenorrha3a,  517,  522 
treatment  of  dysmenorrhoea,  285 
Introduction  of  open  lever  pessary,  dia- 
gram of,  423 
Iodine  injections,  treatment  of  ovarian 

dropsy,  479 
Irritability,  after  inflammation,  151 
deflnition  of,  69 
modifications  of,  70 
opinion  of  authors,  34 
Irritable  bladder  and  urethra,  symptoms 
of,  211 
treatment  of,  304 
diseases,  69 


Irritable  diseases,  causes  of,  225 
diagnosis  of,  240 
pathology  of,  225,  238 
prognosis  of,  241 
lymphatic  glands,  treatment  of,  309, 

477 
rectum,  symptoms  of,  206 

treatment  of,  301 
uterus,  definition  of,  99 

general  symptoms  of,  167 
local  symptoms  of.  105 
progress  and  results  of,  205 
treatment  of,  243 
vulva    and   vagina,  symptoms    of, 
208 
treatment  of,  302 
Irritants,  definition  of,  69 
Irritation  and  enlargements  of  ovaries, 
symptoms  of,  215 
cerebral,  169 
cerebro-spinal,  168 
definition  of,  69 
diseases  of,  67 
nervous,  75,  81 
of  lymphatic  glands,  symptoms  of, 

219 
of  pelvic  nerves,  symptoms  of,  221 

treatment  of,  309 
organic,  75 
spinal,  168 


K. 


Kidneys,   reflex   influences   of  irritable 
uterus,  199 


L. 


Lactation,  cause   of  irritable   diseases, 

232 
Leucorrhoea,  opinion  of  authors,  47 

pessaries  in  the  treatment  of,  296, 

448 
symptom  of  irritable  uterus,  118 
treatment  of,  295 

•with  displacements  of  uterus,  treat- 
ment of,  448 
Levatores  ani  muscles,  326 
Lever  for  removal  of  globular  and  other 
pessaries,  diagram  of,  393 
pessaries,  closed,  419 
description  of,  413 
diagrams  of,  415 
open,  414 
Ligaments  of  uterus,  321 
Local  symptoms  of  irritable  uterus,  105 
Lymphatic  glands,  irritations  of,  219 
treatment  of  enlargements  of,  477 


INDEX. 


529 


M. 


Material  of  pessaries,  387 
Mechanical  dysmenorrhoea,  123 
Meigs'  spring  ring  pessary,  401 
Membranous  dysmenorrhoea,  126 
Menorrhagia,  opinion  of  authors,  42 

pessaries  in  the  treatment  of,  290, 

448 
symptom  of  irritable  uterus,  117 
treatment  of,  289 

with  displacements  of  uterus,  treat- 
ment of,  448 
Menstrual  disturbances,  treatment  of,  284 
Menstruation,  tardy,  509 
Mental  excitements,  cause  of  irritable 

diseases,  233 
Metritis,  130 

cervical,  137 
corporeal,  140 
opinion  of  authors,  57 
treatment  of,  15(j 
Modification  of  Simpson's  intra-uterine 

pessary,  diagram  of,  415 
Modified  intra-uterine  pessary  in  posi- 
tion, diagram  of,  411 
Moral   excitements,   cause    of    irritable 

diseases,  233 
Muscular  effort,    cause  of  irritable  dis- 
ease, 234 


N. 


Natural  position  of  pelvic  viscera,  dia- 
gram of,  317 
Nerves  of  pelvis,  314 
Nervous  irritation,  75,  81 

consequences  of,  67 
Nervous,  definition  of,  71 
sedation,  482 

temperament,  cause  of  irritable  dis- 
eases, 226 
Neuralgia,  definition  of,  84,  101 
Neurotic  diseases,  definition  of,  71 
"  Nimia  Venus,"  cause  of  irritable  dis- 
eases, 233 


0. 


Obliquity  of  pelvis,  328 

Open  lever  pessary,  description  of,  414 

diagrams  of,  415 

in  position,  diagram  of,  416 

introduction  of,  423 

removal  of,  424 
Operations  on  vagina,  treatment  of  dis- 
placements of  uterus,  375 
Organic  irritation,  75 

sedation,  482 
Os  uteri,  ectropion  of,  137 

34 


Ovarian  dropsy,  treatment  of,  478 
tumors,  cases  of,  469 
diagnosis  of,  464 
treatment  of,  292,  308,  478 
Ovaries,  diagnosis  of  enlargements  and 
displacements  of,  464 
enlargements  of,  215 
inflammation  of,  61 
irritations  of,  215 

treatment  of  enlargements  and  dis- 
placements of,  478 
tumors  of,  464 
Ovariotomy,  treatment  of  dropsy  of  the 
ovaries,  478 
treatment  of  ovarian  tumors,  478 
Ovaritis,  opinion  of  authors,  61 


"Packing  system,"  treatment  of  irritable 

uterus,  269 
Pain  and  distressing  sensations,  symp- 
toms of  irritable  uterus,  105 
Palpitations  of  heart,  reflex  influence  of 

irritable  uterus,  187 
Partial  retroversion,  with  flexion,  dia- 
gram of,  337 
Parturient  state,  cause  of  irritable  dis- 
eases, 228 
Parturition,  cause  of  irritable  diseases, 

232 
Passive  congestion,  76 

consequence  of  sedation,  485 
Pathology  of  irritable  diseases,  225,  238 
Pelvic  cellulitis,  63 
fascia  326 
nerves,  314 

diagram  of,  315 
irritations  of,  221 
peritonitis,  147 
Peritonitis,  pelvic,  147 

peri -uterine,  147 
Peri-uterine  peritonitis,  147 
Pessaries,  air,  397 
"bow,"  420 
concavo-convex,  393 
forms  of,  390 
globular,  391 
"horse-shoe,"  414 
lever,  413 
material  of,  387 
objections  to,  385 
plano-convex,  395 
ring,  397 
"S,"420 
stem,  401 
treatment  of  displacements  of  uterus, 

384 
treatment  of  dysmenorrhoea,  287 
treatment  of  hypertrophy  of  uterus, 
449 


580 


INDEX. 


Pessaries,  treatment  of  inflammation  of 
uterus,  158,  297 
treatment  of  leueorrhoea,  296,  448 
treatment  of  menorrhagia,  290,  448 
treatment  of  sterility,  288 
treatment  of  uterine  tumors,  454 
"U,"  414 
value  of,  384 
Physometra,  192 
Polypus  causing  hypertrophy  of  uterns, 

treatment  of,  449 
Pregnancy,  diagnosis  from  amenorrhcea, 

509 
Pressure,  cause  of  irritable  diseases,  235 
Probe,  uterine,  447 
Procidentia  of  uterus,  338 
diagram  of,  338 
treatment  of,  439 
Prognosis  of  displacements   of  uterus, 
365 
of  irritable  diseases,  241 
Progress  and  results  of  irritable  uterus, 

205 

Prolapsus  of  uterus,  330 

diagram  of,  331 

treatment  of,  435 

with  flexion,  332 

diagram  of,  331 


R. 

Rectocele,  440 
Rectum,  hernia  of,  440 

irritable,  206 
Reflex  influences  of  cerebral  and  spinal 

irritations,  180 
Removal  of  open  lever  pessary,  424 
Retroflexion  of  uterus,  336 

treatment  of,  437 
Retroversion  of  uterus,  334 

diagram  of,  335 

treatment  of,  437 

with  flexion,  336 

diagram  of,  337 
Rheumatism,  cause  of  amenorrhcea,  499 

cause  of  irritable  diseases,  228 

of  the  uterus,  treatment  of,  253 
Round  ligaments  of  uterus,  322 


"  S"  pessary,  420 

Sedation  and  its  consequences,  481 

definition  of,  69 

diseases  of,  481 

of  the  uterus,  description  of,  491 

treatment  of,  487 
Simple  dysmenorrhoea,  109 
Simpson's  intra-uterine  pessary,  402 

modified,  diagram  of,  415 

modification  of,  410 


Sims'  uterine  elevator,  370 

Small  intestines,  relation  to  uterus,  327 

Small  lever,  diagram  of,  393 

Sound,  uterine,  447 

Spinal  irritations,  symptoms  of  irritable 

uterus,  168 
Speculum  examinations,  113 
Sterility,  pessaries  in  the  treatment  of, 

288 
Strictures  of  cervix  uteri,  138 

cause  of  irritable  diseases,  236 
Supports  of  uterus,  319 
"  Suppressio  mensium,"  498 
Symptoms  of  displacements   of  uterus, 
346 
of  irritable  uterus,  local,  105 
general,  167 


Temperament,  nervous,  226 
Toxicsemia,  definition  of,  95 
Treatment  of  complications  of  displace- 
ments of  uterus,  447 
of  displacements  of  uterus,  367 
of  enlargements  and  displacements 

of  ovaries,  478 
of  irritable  uterus,  243 
of  sedation,  487 
of  tumors  of  uterus,  451 
Tumors  of  ovaries,  cases  of,  469 
diagnosis  of,  464 
treatment  of,  292,  308,  478 
of  uterus,  causes  of  displacements, 
343 
excision  of,  456 
pessaries  in  the  treatment  of, 

454 
treatment  of,  292,  451 
Tympanites,  reflex  influence  of  irritable 
uterus,  191 


U, 


"  U"  pessary,  414 

Ulcers  of  cervix  uteri,  134 

Urethra,  irritable,  211 

Uterine  probe  or  sound,  diagram  of,  447 

tumors,  treatment  of,  292,  451 
Utero-sacral  ligaments,  324 
Utero-vesical  ligaments,  324 
Uterus,  absence  of,  494 

abscess  of,  140 

and  its  ligaments  (posterior  view), 
diagram  of,  322 

(view  from  above),  diagram  of, 
323 

anteversion  of,  332 

congestion  of,  37,  113 

flexion  of,  332,  334,  336 


INDEX. 


531 


Uterus,  hypertrophy  of,  51,  115,  140 
inflammation  of,  57,  130 
irritability  of,  34,  99 
irritable,  99 
ligaments  of,  321 
prolapsus  of,  330 
position  of,  314 
procidentia  of  uterus,  338 
retroversion  of,  334 
supports  of,  319 
treatment  of  tumors  of,  292,  451 


V. 

Vagina,  direction  of,  318 
displacements,  440 
irritable,  208 


Vagina,  operations  upon,  375 

support  of  uterus,  320 
Vaginal  examinations.  111 

diagnosis  of  displacements 
of  uterus,  356 
operations  for   excision  of  uterine 
tumors,  456 
Vaginismus,  symptoms  of,  208 

treatment  of,  302 
Venesection,  treatment  of  irritable  ute- 
rus, 275 
Vulcanite,  material  for  pessaries,  390 
Vulva,  irritable,  208 


Z. 

Zwancke's  pessary,  396 


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about  three  hundred  octavo  pages,  appropriately  illustrated  wherever  necessary,  A 
lar^e  portion  of  this  space  is  devoted  to  Original  Communications,  embracing  papers 
from  the  most  eminent  members  of  the  profession  throughout  the  country. 

Following  this  is  the  Review  Department,  containing  extended  reviews  by  com- 
petent writers  of  prominent  new  works  and  topics  of  the  day,  together  with  numerous 
elaborate  Analytical  and  Bibliographical  Notices,  giving  a  fairly  complete  survey  of 
medical  literature. 

Then  follows  the  Quarterly  Summary  of  Improvements  and  Discoveries 
IN  the  Medical  Sciences,  classified  and  arranged  under  diflerent  heads,  and  furn- 
ishing a  digest  of  medical  progress,  abroad  and  at  home. 

Thus  during  the  year  1879  the  "Journal"  contained  67  Original  Communications, 
mostly  elaborate  in  character,  147  Reviews  and  Bibliographical  Notices,  and  215  articles 
in  the  Quarterly  Summaries,  illustrated  with  70  wood  engravings. 

That  the  efforts  thus  made  to  maintain  the  high  reputation  of  the  "Journal"  are 

successful,  is  shown  by  the  position  accorded  to  it  in  both  America  and  Europe  as  a 

leading  organ  of  medical  progress:  — 

This  is  universally  acknowledged  as  the  leading  i  The  Philadelphia  Medical  and  Physical  Journal 
Ameiicau  Journal,  and  has  been  conducted  by  Dr.  issued  its  first  number  in  1  820,  and,  after  a  brilliant 
Hays  alone  until  1869,  when  his  son  was  associated  I  career,  was  succeeded  in  1827  by  the  American 
wiih  him.  We  quite  agree  with  the  critic,  that  this  i  Journal  of  the  Medical  Sciences,  a  periodical  of 
journal  is  second  to  none  in  the  language,  and  cheer- 1  world-wide  reputation;  the  ablest  and  one  of  the 
I'ullv  accord  to  it  the  first  place,  for  nowhere  shall  oldest  periodicals  in  the  world — a  journal  which  has 
we  iind  more  able  and  more  impartial  criticism,  and  1  an  unsullied  record. —  Gross's  History  of  American 
nowhere  such  a  repertory  of  able  original  articles.  \  Med.  Literature,  1S76. 

Indeed,  now  that  the  "British  and  Foreign  Medico-       rpj^g  bestmedical  journal everpuhlished  in  Europe 
Chirurgical  Review     has  terminated  its  career,  the    ^j  America.— Ka.  Mtd.  Monthly,  May,  1879. 
American  Journal  stands  without  a  rival. — London  \      ,^. . ,, , ,  .i_"j  i.%l_iv. 


Med.  Times  and  Gazette,  Nov.  24, 1877 

The  best  medical  journal  on  the  continent. — Bos- 
ton Med.  and  Surg.  Journal,  April,  1879. 

The  present  number  of  the  American  Journal  is 
an  exceedingly  good  one,  and  gives  every  promise 
of  maintaining  the  well-earned  reputation  of  the 
review.  Our  venerable  contemporary  has  our  best 
wishes,  and  we  can  only  express  the  hope  that  it 
may  continue  its  work  with  as  much  vigor  and  ex- 
cellence for  the  next  fifty  years  as  it  has  exhibited 
in  the  past.— iondow  Lancet,  Nov.  24, 1877. 


It  is  universally  acknowledged  to  be  the  leading 
American  medical  journal,  and,  in  our  opinion,  is 
second  to  none  in  the  language. — Boston  Med.  and 
Surg.  Journal,  Oct.  1877. 

This  is  the  medical  Journal  of  our  country  to  which 
the  American  physician  abroad  will  point  with  the 
greatest  satisfaction,  as  reflecting  the  state  of  medi- 
cal culture  in  his  country.  For  a  great  many  years 
it  has  been  the  medium  throuj-'h  which  our  ablest 
writers  have  made  known  their  discoveries  and 
observations.— .4drfr#s.9  of  L.  P.  YntidM,  M.D.,  be- 
fore International  Med.  Congress,  Sept.  1876. 


And  that  it  was  specifically  included  in  the  award  of  a  medal  of  merit  to  the  Pub- 
lishers in  the  Vienna  Exliibition  in  1873. 

The  subscription  price  of  the  "American  Journal  of  the  Medical  Sciences" 
has  never  been  raised  during  its  long  career.  It  is  still  Five  Dollars  per  annum  5 
and  when  paid  for  in  advance,  the  subscriber  receives  in  addition  the  "Medical 
News  and  Abstract,"  making  In  all  nearly  2000  large  octavo  pages  per  annum,  free 
of  postage. 

THE  MEDICAL  NEWS  AND  ABSTRACT. 

Thirty-seven  years  ago  the  "Medical  News"  was  commenced  as  a  monthly  to 
convey  to  the  subscribers  of  the  "American  Journal"  the  clinical  instruction  and 

*  C(linmnaicationB  are  invited  from  gentlemen  in  all  parts  of  the  country.  Elaborate  articles  inserted 
l»y  the\E<iitor  are  paid  for  by  the  publishers. 


Henry  C.  Leas's  Son  &  Co.'s  Publications — (Am.  Journ.  Med.  Sn'.).    3 

current  information  which  could  not  be  accommodated  in  the  Quarterly.  It  consisted 
of  sixteen  pages  of  such  matter,  together  with  sixteen  more  known  as  the  Library 
Department  and  devoted  to  the  publishing  of  books.  With  the  increased  progress  of 
science,  however,  this  was  found  insufficient,  and  some  years  since  another  periodical, 
known  as  the  "Monthly  Abstract,"  was  started,  and  was  furnished  at  a  moderate 
price  to  subscribers  to  the  "American  Journal."  These  two  monthlies  will  here- 
after be  consolidated,  under  the  title  of  "The  Medical  News  and  Abstract," 
and  will  be  furnished  fi-ee  of  charge  in  connection  with  the  "American  Journal." 

The  "  News  and  Abstract"  will  consist  of  64  pages  monthly,  in  a  neat  cover.  It 
will  contain  a  Clinical  Department  in  which  will  be  continued  the  series  of  Origi- 
nal American  Clinical  Lectures,  by  gentlemen  of  the  highest  reputation 
throughout  the  United  States,  together  with  a  choice  selection  of  foreign  Lectures  and 
Hospital  Notes  and  Gleanings.  Then  will  follow  the  Monthly  Abstract,  systemati- 
cally arrauged  and  classified,  and  presenting  five  or  six  hundred  articles  yearly  ;  and 
each  number  will  conclude  with  a  News  Department,  giving  current  jJi'ofessional 
intelligence,  domestic  and  foreign,  the  whole  fully  indexed  at  the  close  of  each  volume, 
rendering  it  of  permanent  value  for  reference. 

As  stated  above,  the  subscription  price  to  the  "News  and  Abstract"  will  be 
Two  Dollars  and  a  Half  per  annum,  invariably  in  advance,  at  which  rate  it  will  rank 
as  one  of  the  cheapest  medical  periodicals  in  the  country.  But  it  will  also  be  fur- 
nished, free  of  all  charge,  in  commutation  with  the  "American  Journal  of  the 
Medical  Sciences,"  to  all  who  remit  Five  Dollars  in  advance,  thus  givino-  to  the 
subscriber,  for  that  very  moderate  sum,  a  complete  record  of  medical  progress  through- 
out the  world,  in  the  compass  of  about  two  thousand  large  octavo  pages. 

In  this  effort  to  furnish  so  large  an  amount  of  practical  information  at  a  price  so  un- 
precedentedly  low,  and  thus  place  it  within  the  reach  of  every  member  of  the  profes- 
sion, the  publishers  confidently  anticipate  the  friendly  aid  of  all  who  feel  an  interest  in 
the  dissemination  of  sound  medical  literature.  They  trust,  especially,  that  the  sub- 
scribers to  the  "American  Medical  Journal,"  will  call  the  attention  of  their 
acquaintances  to  the  advantages  thus  offered,  and  that  they  will  be  sustained  in  the 
endeavor  to  permanently  establish  medical  periodical  literature  on  a  footiu"-  of  cheap- 
ness never  heretofore  attempted. 

PEEMIUM  rOE  OBTAINING  NEW  SUBSOEIBEES  TO  THE  "JOUENAL." 

Any  gentleman  who  will  remit  the  amount  for  two  subscriptions  for  1880,  one  of 
which  at  least  must  be  for  a  7ieio  siibscriher,  will  receive  as  a  premium,  free  by  mail, 
a  copy  of  any  one  of  the  following  recent  Avorks  : — 

"Barnes's  Manual  of  Midwifery"  (see  p.  24), 

"Tilbury  Fox's  Epitome   of  Diseases  of  the  Skin,"  new  edition  (see 

p.  18), 
"Fothergill's  ANTAGONisai  of  Medicines"  (see  p.  16), 
"Holden's  Landmarks,  Medical  and  Surgical"  (see  p.  6), 
"Browne  on  the  Use  of  the  Ophthalmoscope"  (see  p.  29), 
"Flint's  Essays  on  Conservative  Medicine"  (see  p,  15), 
"  Sturges's  Clinical  Medicine"  (see  p.  14), 
"  SwAYNE's  Obstetric  Aphorisms,"  new  edition  (see  p.  21), 
"Tanner's  Clinical  Manual"  (see  p.  5), 
"  AVest  on  Nervous  Disorders  of  Children"  (see  p.  20). 

*^*  Gentlemen  desiring  to  avail  themselves  of  the  advantages  thus  offered  will  do 
well  to  forward  their  subscriptions  at  an  early  day,  in  order  to  insure  the  receipt  of 
complete  sets  for  the  year  1880. 

i^°  The  safest  mode  of  remittance  is  by  bank  check  or  postal  money  oi-der,  drawn 
to  the  order  of  the  undersigned.  Where  these  are  not  accessible,  remittances  for  the 
"Journal"  maybe  made  at  the  risk  of  the  publishers,  by  forwarding  in  registered 
letters.     Address, 

Henry  C.  Lea's  Son  &  Co.,  Nos.  706  and  708  Sansom  St.,  Phiia.,  Pa. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — {Dictionaries). 


jnUNOLISON  {ROBLEY),  M.D., 

Late  Professorof  Institutes  of  Medicinein  Jefferson  Medical  Qollege,  Philadelphia, 

MEDICAL  LEXICON;  A  Dictionary  of  Medical  Science:  Con- 
taining a  concise  explanation  of  the  various  Subjects  and  Terms  of  Anatomy,  Physiology, 
Pathology,  Hygiene,  Therapeutics,  Pharmacology,  Pharmacy,  Surgery,  Obstetrics,  Medical 
Jurisprudence,  and  Dentistry.     Notices  of  Climate  and  of  Mineral  Waters  ;  Formulae  for 
Ofacinal,  Empirical,  and  Dietetic  Preparations;  with  the  Accentuation  and  Etymology  of 
the  Terms,  and  the  French  and  other  Synonymes ;  so  as  to  constitute  a  French  as  well  as 
English  Medical  Lexicon.     A  New  Edition.     Thoroughly  Revised,  and  very  greatly  Mod- 
ified and  Augmented.     By  Richard  J.  Dunglison,  M.D.     In  one  very  large  and  hand- 
some  royaloctavo  volume  of  over  1100  pages.    Cloth,  $6  50  ;  leather,  raised  bands,  $7  50  ; 
half  Russia,  &.8.      iJust  Issued.) 
The  object  of  the  author  from  the  outset  has  not  been  to  make  the  work  a  mere  lexicon  or 
dictionary  of  terms,  but  to  afford,  undereach,  a  condensed  view  of  its  various  medical  relations, 
and  thus  to  render  the  work  an  epitome  of  the  existing  condition  of  medical  science.    Starting 
with  this  view,  the  immense  demand  which  has  existed  for  the  work  has  enabled  him,  in  repeated 
revisions,  to  augment  its  completeness  and  usefulness,  until  at  length  it  has  attained  the  position 
■of  a.  recognized  and  standard  authority  wherever  the  language  is  spoken. 

Special  pains  have  been  taken  in  the  preparation  of  the  present  edition  to  maintain  this  en- 
viable reputation.  During  the  tf  n  years  which  have  elapsed  since  the  last  revision,  the  additions 
to  the  nomenslature  of  the  medical  scienceshave  been  greater  than  perhaps  in  any  similar  period 
of  th«  past,  and  up  to  the  time  of  his  death  the  authorlabored  assiduously  to  incorporate  every- 
thing requiring  the  attention  of  the  student  or  practitioner.  Since  then,  the  editor  has  been 
equally  industrious,  so  that  the  additions  to  the  vocabulary  are  more  numerous  than  in  any  pre- 
vious revision.  Especial  attention  has  been  bestowed  on  the  accentuation,  which  will  be  found 
marked  on  every  word.  The  typigraphioal  arrangement  has  been  much  improved,  rendering 
reference  much  more  easy,  and  every  care  has  been  taken  with  the  mechanical  execution.  The 
work  has  been  printed  on  new  type,  small  but  exceedingly  clear,  with  an  enlarged  page,  so  that 
the  additions  have  been  incorporated  with  an  increase  of  but  little  over  a  hundred  pages,  and 
the  volume  now  contains  the  matter  of  at  least  four  ordinary  octavos. 


A  bo<ik  well  known  to  our  reader.*,  and  of  which 
every  Anieri«an  ought  to  bepi'oud.  When  the  learned 
author  ot  the  work  pas.sed  uway,  probably  all  of  us 
feared  lest  the  book  should  not  maintain  its  place 
in  the  advancing  science  whose  terms  it  defines.  For- 
tunately, L>r.  Richard  J.  Dunjiilison,  having  assisted  his 
father  in  the  revision  of  several  edition.s  of  the  work, 
and  having  been,  therefore,  trained  in  the  methods  and 
imbued  with  the  spirit  of  the  book,  has  been  able  to 
edit  it,  not  In  the  patchwork  manner  .so  dear  to  the 
heart  of  book  editors,  so  repulsive  to  the  taste  of  intel- 
ligent book  readers,  but  to  edit  it  as  a  work  of  the  kind 
should  be  edited — to  carry  it  on  steadily,  without  jar 
or  interruption,  along  the  grooves  of  thought  it  has 
travelled  during  its  lifetime.  To  show  the  magnitude 
of  the  task  which  Dr.  Dunglison  has  assumed  and  car- 
ried throui;h,it  is  only  nece.ssary  to  state  that  more 
than  six  thousand  new  subjects  have  been  added  in  the 
present  edition. — Flnla.  Med.  Times,  Jan.  3,  18T4. 

About  the  first  book  purchased  by  the  medical  stu- 
dent is  the  Medical  Dictionary.  The  lexicon  explana- 
tory of  technical  terms  is  simply  a  sine  qua  non.  In  a 
science  so  e.^: tensive,  and  with  such  collaterals  as  medi 
cine,  it  is  a.'*  much  a  necessity  also  to  the  practising 
physician.  To  meet  the  wants  of  students  and  most 
physicians,  the  dictionary  must  be  condensed  while 
comprehensive,  and  practical  while  perspicacious.  It 
was  because  Uunglison's  met  these  indications  that  it 
became  at  once  the  dictionary  of  general  use  wherever 
medicine  was  studied  in  the  English  language.  In  no 
former  revision  have  thealterations  and  additions  been 
80  great.  Mjre  than  six  thousand  new  subjects  and  terms 
have  been  added.  The  chief  terms  have  been  set  in  black 
letter,  while  the  derivatives  follow  in  small  caps;  an 
arrangement  which  greatly  facilitates  reference.     We 


may  safely  confirm  the  hope  ventured  by  the  editor 
"  that  the  work,  which  possesses  for  him  a  filial  as  well 
IS  an  individual  interest,  t»ill  be  found  worthy  a  con- 
tinuance of  the  po.sition  so  long  ac(;orded  to  it  as  a 
standard  authority ."^ — Oincinnau  Clinic.  Jan.  10, 1874. 

It  has  the  rare  merit  that  it  certainly  has  n*  rival 
in  the  English  language  for  accuracy  and  extent  of 
references. — London  Medical  Onzette 

As  a  standard  work  of  reference,  as  one  of  the  best, 
if  not  the  very  best,  medical  dictionary  in  the  Eng- 
lish language,  Dunglison's  work  has  been  well  known 
for  about  forty  years,  and  needs  no  words  of  praise 
on  our  part  to  recommend  it  to  the  meniliers  of  the 
medical,  and,  likewise,  of  the  pharmaceutical  pro 
fe.ssiou.  The  latter  especially  are  in  need  of  such  a 
work,  which  gives  ready  and  reliable  information 
ou  thousands  of  subjects  and  terms  which  they  are 
liable  to  encounter  in  pursuing  their  daily  avoca- 
tions, but  with  which  they  cannot  be  expected  to  be 
familiar.  The  work  before  us  fully  supplies  this 
want. — Am.  Journ.  of  Pharm.,  Feb.  1S74. 

A  valuable  dictionary  of  the  terms  employed  in 
medicine  and  the  allied  sciences,  and  of  the  rela- 
tions of  the  subjects  treated  under  each  head.  It  re- 
Uectg  great  credit  on  its  able  American  author,  and 
well  deserves  the  authority  and  popularity  it  has 
obtained.— JSnVuvA  Med.  Journ., Oct.  M,  1S74. 

Few  works  of  this  class  exhibit  a  grander  monu- 
ment of  patient  research  and  of  scientific  lore.  The 
extent  of  the  sale  of  this  lexicon  is  sufficient  to  tes- 
tify to  its  use'nluess,  and  to  the  greai  service  con- 
ferred by  Dr.  Kobley  Dunglison  ou  the  profession, 
and  indeed  on  others,  by  its  issue. — London  Ldna-t , 
May  13,  1K75. 


fJOBLYN  [RICHARD  D.),  M.D. 

^A  DICTIONARY  OF  THE  TERMS  USED  IN  MEDICINE  AND 

THE  collateral  SCIENCES.     Revised,  with  numerous  additions,  by  Lsaac  Hays, 
M.D.,  Editor  of  the  "American  Journal  of  the  Medical  Sciences."     In  one  large  royal 
12mo.  volume  of  over  500  double-columned  pages  ;  cloth,  $1  60;  leather,  $2  00 
It  is  thii  best  bodk  of  definitions  we  have,  and  ought  always  to  be  upon  the  student's  l&hle.— Southern 
Med.  and  Surg.  Journal. 

pODWELL  [G.  F.),  F.R.A.S.,  §t. 

A  DICTIONARY  OF  SCIENCE:  Comprising  Astronomy,  Chem- 
istry, Dynamics,  Electricity,  Heat,  Hydrodynamics,  Hydrostatics,  Light,  Magnetism, 
Mechanics,  Meteorology,  Pneumatics,  Sound,  and  Statics.  Preceded  by  an  Essay  on  the 
History  of  the  Physical  Sciences.  In  one  handsome  octavo  volume  of  694  pages,  and 
many  illustrations  :  cloth,  $6. 


Henky  C.  Lea's  Son  &  Co.'s  Publications — {3Ianuals).  5 

A  CENTURY  OF  AMERICAN  MEDICINE,  ril6-lS16.  By  Doctors  E.  H. 
-^^  Clarke,  H.  J.  Bigelow,  S.  D.  Gross,  T.  G.  Thomas,  and  J.  S.  Billings.  Inone  very  hand- 
some 12mo.  volume  of  about  350  pages  :  cloth,  $2  26.      (Lately  Issued.) 

This  work  appeared  in  the  pages  of  the  American  Journal  of  the  Medical  iSciencesduring  the 
year  1876.  As  a  detaileti  account  of  the  development  of  medical  science  in  America,  by  gentle- 
men of  the  highest  authority  in  their  respective  departments,  the  profession  will  no  doubt  wel 
come  it  in  a  form  adapted  for  preservation  and  reference. 


l^EILL  {JOHN),  M.D.,  and     OMITH  {FRANCIS  G.),  M.D., 

Prof,  of  the  Institutes  of  Medicine  inthe  Univ.  of  Penna 

AN   ANALYTICAL    COMPENDIUM   OF   THE    VARIOUS 

BRANCHES  OF  MEDICAL  SCIENCE;  for  the  Use  and  Examination  of  Students.  A 
new  edition,  revised  and  improved.  In  one  very  large  and  handsomely  printed  royal  12m(). 
volume,  of  about  one  thousand  pages,  with  374  wood-cuts,  cloth,  $4  ;  strongly  bound  in 
leather,  with  raised  bands,  $4  75. 


TJARTSHORNE  {HENRY),  M.D., 

Professor  of  Hygiene  in  the  University  of  Pennsylvania. 

A    CONSPECTUS    OF    THE   MEDICAL    SCIENCES;    containing 

Handbooks  on   Anatomy,  Physiology,  Chemistry,  Materia   Medica,   Practical  Medicine, 
Surgery,  and  Obstetrics.   Second  Edition,  thoroughly  revised  and  improved.  In  one  large 
royal  12mo.  volume  of  more  than  1000  closely  printed  pages,  with  477  illustrations  on 
wood.     Cloth,  $4  25  ;  leather,  $5  00.     {Lately  Issued.) 
We  can  say  with  the  strictest  truth  (hat  it  is  the 

best  work  of  the  kind  with  which  wf  art  acquainted. 

It  embodies  ina  condensed  form  ail  recent  coutribu- 


tions  to  practical  medicine,  and  is  therefore  useful 
to  every  busy  practitioner  throughout  our  country, 
besides  being  admirably  adapted  to  the  use  of  stu- 
dents of  medicine.  The  book  is  faithfully  and  ably 
executed.— C'/taWe.ston  Med.  Journ.,  April,  187.5. 

The  work  is  Intended  as  an  aid  to  the  medical 
stulent,  and  as  such  appears  to  admirably  fulfil  its 
object  by  itsexcellent  arrangement,  the  full  compi- 
lation of  facts,  the  perspicuity  aud  terseues.s  of  lan- 
guage, and  the  clear  and  instructive  illustrations 
in  some  parts  of  the  work. — American  Journ.  of 
Phai'macy ,  Philadelphia,  July,  187-t. 

The  volume  will  be  found  useful,  not  only  to  stu- 
dents, but  to  many  otherswhomay  desire  torefresh 
their  memories  with  the  smallest  possible  expendi- 
ture of  time. — N.  Y.  Med.  Journal,  Sept.  1874. 

The  student  will  find  this  the  most  convenient  and 
useful  book  of  the  kind  on  which  he  can  lay  his 
hand. — Pacific  Med.  and  Surg.  Journ.,  Aug.  1874. 

This  is  the  best  book  of  its  kind  that  we  have  ever 
examined.  It  is  an  honest,  accurate,  and  concise 
compend  of  medical  sciences,  as  fairly  as  possible 
representing  their  present  condition.  The  changes 
and  the  additions  have  been  so  judicious  and  tho- 
rough as  to  render  it,  so  far  as  it  goes,  entirely  trust- 


worthy. If  students  must  have  a  conspectus,  they 
will  be  wise  to  procure  that  of  Dr.  Hartshorne.— 
Detroit  Rev.  of  Med.  and  Pharm.,  Aug.  1874. 

The  work  before  us,  however,  has  many  redeem- 
ing features  not  possessed  by  others,  and  is  the  best 
wehaveseen.  Dr.  Hartshorne  exhibits  much  skill  in 
condensation.  It  is  well  adapted  to  the  physician  in 
active  practice,  who  can  give  but  limited  time  to  the 
familiarizing  of  himself  with  the  important  changes 
which  have  been  made  since  he  attended  lectures. 
The  manual  of  physiology  has  also  been  improved 
and  gives  the  most  comprehensive  view  of  the  latest 
advances  in  the  science  po.ssible  in  the  space  devoted 
to  the  subject.  The  mechanical  es'Bcution  of  the 
book  leaves  nothing  to  be  wished  for. — Peninsular 
Journal  of  Medicine,  Sept.  1874. 

After  carefully  looking  through  this  conspectus, 
we  are  constrained  to  say  that  it  is  the  most  com- 
plete work,  especially  in  its  illustrations,  of  its  kind 
that  we  have  seen. — Cincinnati  Lancet,  Sept.  1874. 

The  favor  with  which  the  first  edition  of  this 
Compendium  was  received,  was  an  evidence  of  its 
various  excellences.  The  present  edition  bears  evi- 
dence of  a  careful  and  thorough  revision.  Dr.  Harts- 
horne possesses  a  liappy  faculty  of  seizing  upon  the 
salient  points  of  each  subject,  and  of  presenting  them 
in  a  concise  and  yet  perspicuous  manner. — Leaven- 
worth Med.  Herald,  Oct.  1.S74 


r  UDLOW  {J.L.),  M.D. 
A   MANUAL   OF  EXAMINATIONS  upon  Anatomy,  Physiology, 

Surgery,  Practice  of  Medicine,  Obstetrics,  Materia  Medica,  Chemistry,  Pharmacy,  and 
Therapeutics.  To  which  is  added  a  Medical  Formulary.  Third  edition,  thoroughly  revised 
and  greatly  extended  and  enhirged.  With  370  illustrations.  In  one  handsome  royal 
12mo.  volume  of  816  large  pages,  cloth,  $3  25  ;  leather,  $3  75. 
The  arrangement  of  this  volume  in  the  form  of  question  and  answer  renders  it  especially  suit- 
able for  the  office  examination  of  students,  and  for  those  preparing  for  graduation. 


rPANNER  {THOMAS  HA  WKES),  M.D.,  8fc. 

A  MANUAL  OF  CLINICAL  MEDICINE  AND  PHYSICAL  DIAG- 

NOSIS.     Third  American  from  the  Second  London  Edition.    Revised  and  Enlarged  by 
Tilbury  Fox,  M.  D.,  Physician  to  the  Skin  Department  in  University  College  Hospital, 
<tc.   In  one  neat  volume  small  12mo.,  of  about  375  pages,  cloth,  $150. 
***  On  page  3,  it  will  be  seen  that  this  work  is  offered  as  a  premium  for  procuring  new 
S'lbseribers  to  the  "American  Journal  of  the  Medical  Sciences." 


6  Henry  C.  Lea's  Son  &  Co.'s  Publications — (Anatomy). 

fIRAY  [HENRY),  F.R.S., 

^^  Lecturer  on  Anatomy  at  St.  Oeorge^s  Hospital,  London. 

ANATOMY,  DESCRIPTIVE    AND  SURGICAL.     The  Drawings  by 

H.  V.  Carter,  M.D.,  and  Dr.  Westmacott.    The  Dissectionsjointly  by  the  Author  and 
Dr.  Carter.     AVith  an   Introduction    on    General    Anatomy  and  Development  by  T. 
Holmes,  M.A.,  Surgeon  to  St.   George's  Hospital.     A  new  American,  from  the  eighth 
enlargei  and  improved  London  edition.     To  which  is  added  "  Landjiarks,  Medical  and 
Surgical,"'  by  Luther  Holden,  F.R.C.S.,  author  of"  Human  Osteology,"  "  A  Manual 
of  Dissections,"   etc.     In  one  magnificent  imperial   octavo  volume  of  983   pages,  with 
622  large  and  elaborate  engravings  on  wood.     Cloth,  $6;  leather,  raised  bands,  $7; 
half  Russia,  $7 '50.     {Just  Ready.) 
The  author  has  endeavored  in  this  work  to  cover  a  more  extendedrangeofsubjectsthan  iscuE- 
tomary  in  the  ordinary  text-books,  by  giving  not  only  the  details  necessary  for  the  student,  but 
also  the  applicationof  those  details  in  the  practiceof  medicine  andsurgery,  thusrendering  it  both 
a  guide  for  the  learner,  and  an  admirable  work  of  reference  for  the  active  practitioner.   The  en- 
gravings form  a  special  feature  in  the  work,  many  of  them  being  the  size  of  nature,  nearly  all 
original,  and  having  the  names  of  the  various  parts  printed  on  the  body  of  the  cut,  in  place  of 
figures  of  reference,  with  descriptions  at  the  foot.  They  thus  form  a  complete  and  splendid  series, 
which  will  greatly  assist  the  student  in  obtaining  a  clear  idea  of  Anatomy,  and  will  also  serve  to 
refresh  the  memory  of  those  who  may  find  in  the  exigencies  of  practice  the  necessity  of  recalling 
the  details  of  the  dissecting  room  ;  while  combining,  as  it  does,  a  complete  Atlas  of  Anatomy,  with 
a  thorough  treatise  on  systematic,  descriptive,  and  applied  Anatomy,  the  work  will  be  found  of 
essential  use  to  all  physicians  who  receive  students  in  their  offices,  relieving  both  preceptor  and 
pupil  of  much  labor  in  laying  the  groundwork  of  a  thorough  medical  education. 

Since  the  appearance  of  the  last  American  Edition,  the  work  has  received  three  revisions  at  the 
hand.«  of  its  accomplished  editor,  Mr.  Holmes,  who  has  sedulously  introduced  whatever  has  seemed 
requisite  to  maintain  its  reputation  as  a  complete  and  authdritative  standard  text-book  and  work 
of  reference.  Still  further  to  increase  its  usefulness,  there  has  been  appended  to  it  the  recent 
work  by  the  distinguished  anatomist,  Mr.  Luther  Holden — "Landmarks,  Medical  and  Surgical" 
•which  gives  in  a  clear,  condensed,  and  systematic  way,  all  the  information  by  which  the  prac- 
titioner can  determine  from  the  external  surface  of  the  body  the  position  of  internal  parts.  Thus 
complete,  the  work,  it  is  believed,  will  furnish  all  the  assistance  that  can  be  rendered  by  type  and 
illustration  in  anatomical  study.  No  pains  have  been  spared  in  the  typographical  execution  of 
the  volume,  which  will  be  found  in  all  respects  superior  to  former  issues.  Notwithstanding  the 
increase  of  size,  amounting  to  over  100  pages  and  57  illustrations,  it  will  be  kept,  as  heretofore, 
at  a  price  rendering  it  one  of  the  cheapest  works  ever  offered  to  the  American  profession. 

The  recent  work   of  Mr.  Holden,  which  was  no-  i  to   consult   his  books   on   anatomy.    The    work   is 
ticed  by  us  on  p.  53  of  this  volume,  has  been  added    Kiraply  indispen.sable,  especially  this  pre.-ent  Anier- 
as  an  appendix,  so  that,  altogether,  this  is  the  mot  t    icaa  edition.— Fa.  Med.  Monthly,  Sept.  1S7P. 
nractical  and  complete  anatomical  treatise  available  ,  .  u     ,  nr     tr  u 

?o  American  students  and  physicians.     The  former        The  addition  of  the  recen    work  of  Mr   Ho  den 
finds  in  it  the  necessary  guide   in  making  dissec- I  as  an  appendix,  venaers  this  the  most  practical  and 


view,  a 

will   find  all  that  will  be  essential  to  him  in  his 

practice —A'ew  Remedies,  kxi.g.  1S7S. 

This  work  is  as  near  perfection  as  one  could  pos- 
sibly or  reasonably  expect  any  book  intended  as  a 
text-book  or  a  general  reference  book  on  anatomy 
to  be.  The  American  publisher  deserves  the  thanks 
of  thn  profession  for  appending  the  recent  work  of 
Mr.  Holden,  ^'Landmarks,  Medical onn  S'lrgical," 
which  has  already  been  commended  as  a  separate 
book  The  latter  work— treating  of  topographi«al 
anatomy— has  become  an  essential  to  the  library  of 
every  intelligent  practitioner.  We  know  of  no 
book  that  can  take  its  place,  written  as  it  is  by  a 
most  dl!^tingui^hed  anatomist.  It  would  be  simply 
a  waste  of  words  to  say  anything  further  in  praise 
of  Gray's  Anatomy,  the  text-book  in  almost  every 
medical  college  in  this  country,  and  the  daily  refer- 
ence book  of  every  practitioner  who  has  occasion 


ble  section  by  Mr.  Holden.  i.«  all  that  will  be  essen- 
tial to  them  in  practice.— 0/iio  Mtdieal  Recorder, 
Aug   1S7S. 

It  is  difficult  to  speak  in  moderate  terms  of  this 
new  edition  of  "Gray."  It  seems  to  be  as  nearly 
perfect  as  it  is  possible  to  make  a  book  devoted  to 
any  branch  of  medical  science.  The  labors  of  the 
eminent  men  who  have  successively  revised  the 
eight  editions  through  which  it  has  passed,  would 
seem  to  leave  nothing  for  future  editors  to  do.  The 
addition  of  Holden's  "  Landmarks"  will  make  it  as 
indispensable  to  the  practitioner  of  medicine  and 
surgery  as  it  has  been  heretofore  to  the  student.  As 
regards  completeness,  ease  of  reference,  utility, 
beauty,  and  cheapness,  it  has  no  rival.  No  stu- 
dent should  enter  a  medical  school  without  it  ;  no 
physician  can  afford  to  have  it  absent  from  his 
library.— S(.  Loiiis  Clin.  Record,  Sept.  1878. 


Also  for  sale  separate — 
TTOLDEN  [LUTHER),  F.R.C.S., 

-[1  Surgeon  to  St.  Bartholomew's  and  the  Foundling  Hospitals. 

LANDMARKS,  MEDICAL  AND  SURGICAL.    From  the  2d  London 

Ed.   In  one  handsome  volume,  royal  12mo.,  of  128  pages  :  cloth,  88  cents.    (Now  Ready.) 
TIE  ATE  [CHRISTOPHER),  F.R.C.S., 

-/3  Teacher  of  Operative  Surgery  in  University  College,  London. 

PRACTICAL  ANATOMY:    A  Manual  of  Dissections.     From  the 

Second  revised  and  improved  London  edition.  Edited,  with  additions,  by  W.  W.  Keen, 
.    M.  D.,  Lecturer  on  Pathological  Anatomy  in  the  Jefferson  Medical  College,  Philadelphia. 
In  one  handsome  royal  12mo. volume  of  678  pages,  with  247illustrationB.  Cloth,  $3  50  ; 
leather,  $4  00. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (A?iatomy).  T 

A  LLEN  (HARRISON),  M.D. 

■^^  Profegnor  of  Physiology  in  the  Univ.  of  Pa. 

A  SYSTEM  OP  HUMAN  ANATOMY:  INCLUDING  ITS  MEDICAL 

and  Surgical  Relations.  For  the  Use  of  Practitioners  and  Studentsof  Medicine.   With  an 
Introductory  Chapteron  Histology.  By  E.  0.  Shakespeare,  M  D.,  Ophthnlmologistto  the 
Phila.  Hosp.    In  one  large  and  handsome  quarto  volume,  with  several  hundred  oriffinal 
illustrations  on  lithographic  plates, "and  numerous  wood-outs  in  the  text.      (In  Press.) 
In  this  elaborate  work,  which  has  been  in  active  preparation  for  several  years,  the  author  has 
sought  to  give,  not  only  the  detail?  of  descriptive  anatomy  in  a  clearand  condensed  form,  but  also 
the  practical  applications  of  the  science  to  medicine  and  surgery.  The  work  thus  has  claims  upon 
the  attention  of  the  general  practitioner,  as  well  as  of  the  student,  enabling  him  not  only  to  re- 
fresh his  recollections  of  the  dissecting  room,  but  also  to  recognize  the  significance  of  all  varia- 
tions from  normal  conditions.     The  marked  utility  of  the  object  thus  sought  by  the  author  is 
self  evident,  and  his  long  experience  and  assiduous  devotion  to  its  thorough  development  are  a 
sufficient  guitrantee  of  the  manner  in  which  his  aims  have  been  carried  out.  No  pains  have  been 
spared  with  the  illustrations.  Those  of  normal  anatomy  are  from  original  dissecti.jns,  drawn  on 
stone  by  Mr.  Hermann  Faber,  with  the  name  of  every  part  clearly  engraved  upon  the  figure, 
after  the  manner  of  "  Holden"  and  "  Gray,  "  and  in  every  typographical  detail  it  will  be  the 
efiFort  of  the  publisher  to  render  the  volume  worthy  of  the  very  distinguished  position  which  is 
anticipated  for  it. 

TpiLIS  [GEORGE  VINER). 

-'-'  Emeritus  Professor  of  Anatomy  in  University  College,  London. 

DEMONSTRATIONS  OP  ANATOMY;  Being  a  Guide  to  the  Know- 
ledge of  the  Human  Body  by  Dissection.  By  George  Viner  Ellis,  Emeritus  Professor 
of   Anatomy  in    University  College,   London.     From  the   Eighth  and  Revised   London 
Edition.     In  one  very  handsome  octavo  volume  of  over  700  pages,  with  256  illustrations. 
Cloth,  $4.25  ;  leather,  $5.25.      {Just  Ready.) 
This  work  has  long  been  known  in  England  as  the  leading  authority  on  practical  anatomy, 
and  the  favorite  guide  in  the  dissecting-room,  as  is  attested  by  the  numerous  editions  throuch 
which  it  has  passed.     In  the  last  revision,  which  has  just  appeared  in  London,  the  accomplished 
author  has  sought  to  bring  it  on  a  level  with  the  most  recent  advances  of  science  by  making  the 
necessary  changes  in  his  account  of  the  microscopic  structure  of  the  different  organs,  as  devel- 
oped by  the  latest  researches  in  textural  anatomy. 

ElUs'ii  Demonstrations  is  the  favorite  text-book    its  leaderehip  over  the  Knglish  maauals  upon  dis- 
of  the   English    student   of   anatomy.     In  passing  |  .secting. — Phila.  Med.  Times,  May  24,  1879. 
through  eight  editions  it  has  been  so  revised  and  \ 

adapted  to  the  needs  of  the  student  hat  it  would  I  ■^'^  *  dissector,  or  a  worlc  to  have  in  hand  and 
seem  that  it  had  almost  reached  perfection  in  thii  |  studied  while  one  is  engaged  in  dissecting,  we  re 
special  line.     The  descriptions  are  clear,  and    the    S^'^d  ^"^  ^s  the  very  best  work  extant,  which  is  cer- 


luethods  of  pursuing  anatomical  investigations  are 
given  with  such  detail  that  the  book  is  honestly 
entitled  to  its  name. — St.  Louis  Clinical  Record, 
June,  1879. 

The  success  of  this  old  manual  seems  to  be  as  well 
deserved  in  the  present  as  in  the  pa^t  volumes. 
The  book  seems  destined  to  maintain  yet  for  years 


tainly  saying  a  very  great  deal.  As  a  text-book  to 
be  studied  in  the  dishecting-room,  it  is  .'^upeiior  to 
any  of  the  works  upon  anatomy.  — Ci/icinrtati  Med. 
Mws,MAj2i,  1879. 

We   most  unreservedly  recommend   it   to  every 

practitioner  of  medicine  who  can  possibly  get  it. 

Va.  Med.  Monthly,  June,  1879. 


w 


ILSON  (ERASMUS),  F.R.S. 

A  SYSTEM  OP  HUMAN  ANATOMY,  General  and  SpeciaL  Edited 

by  W.  H.  GoBRECiiT,  M.D  ,  Professor  of  General  and  Surgical  Anatomyin  the  Medical  Col 

lege  of  Ohio.    Illustrated  with  three  hundred  and  ninety-seven  engravings  on  wood.     In 

one  large  and  handsome  octavo  volume,  of  over  600  large  pages  ;  cloth,  $4  ;  leather,  $5. 

^MITH  (HENRY H.),  M.D.,         and  JJORNER  (  WILLIAM  E.),M.D., 

Prof,  of  Surgery  in  the  Univ.  of  Penna. ,  &e.  Late  Prof,  of  Anatomy  in  the  Univ.  ofPenna. 

AN    ANATOMICAL   ATLAS  ;    illustrative   of  the  Structure  of  the 

Human  Body.  In  one  volume,  large  imperial  octavo,  cloth,  with  about  six  hundred  and 
fifty  beautiful  figures.     $4  50. 

CHAFER  (ED  WARD  ALBERT),  M.D., 

A.isistont  Professor  of  Physiology  in  Vniversity  College,  London 

A  COURSE  OF  PRACTICAL  HISTOLOGY:  Being  an  Introduction  to 

the  Use  of  the  Microscope.     In  one  handsome  royal  12ino.  volume  of  304  pages,  with 
numerous  illustrations:  cloth,  $2  00.     (Just  Issued.) 


s 


HORNER'S  SPECIAL   ANATOMY   AND    HISTOL- ;      for  their  Pass  Examination.   With  engravings  on 

OGY.    Eighth  edition,  extensively  revised  and        wood.     In   one   handsome   royal   12mo.  volume 

modified.     In  2  vols.   8vo.,  of  over  1000  pages,  j      Cloth,  f22o. 

with  ,320  woodcuts  :  cloth,  Si6  00  CLELAND'S  DIRECTORY  FOR  THE  DISSECTION 

SHARPEY    AND    QUAIN'S    HUMAN     ANATOMY.'      OF  THE  HUMAN  BODY.     In  one  binall  volume, 

Revised,  by  Joseph  Leidt,  M.D.,  Prof  of  Anat.  i      royal  12mo.  of  182  pages:  oloth  ^1  25. 

in  Uuiv.  of  Penn.     In  two  octavo  vols,  of  about     haRTSHORNE'S  HANDBOOK  OF  ANATOMY  AND 

1300  pages,  with  oil  Illustrations  Cloth, $600.,  PHYSIOLOGY.  Second  edition,  revised.  In  one 
BELLAMYS    STUDENT'S    GUIDE   TO    SURGICAL  |      royal   12mo.    vol.,   with    220  wood-cuts;    cloth 

ANATOMY;  A  Text-book  for  Students  preparing  \      $1  75. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Physiology). 


pARPENTER  (  WILLIAM  B.),  M.  D.,  F.R.S.,  F.G.S.,  F.L.S., 

^-^  Registrar  to  University  of  London,  etc . 

PRINCIPLES  OF  HUMAN  PHYSIOLOGY;  Edited  by  HenryPower, 

M.B.  Lond.,  F  R.C.S.,  Examiner  in  Natural  Sciences,  University  of  Oxford.  A  new 
American  from  the  Eighth  Revised  and  Enlarged  English  Edition,  with  Notes  and  Addi- 
tions, by  Francis  Gr.  Smith,  M.D.,  Professor  pf  thelnstitutesof  Medicine  in  the  Univer- 
sity ol  Pennsylvania,  etc.  In  one  very  large  and  handsome  octavo  volume,  of  1 088  pages, 
■with  two  plates  and  373  engravings  on  wood;  cloth,  $5  50  ;  leather,  $6  50;  half  Russia, 
$7.  (Just  Issued.) 
We  have  been  agreeably  surprised  to  find  the  vol- 1  new  a  year  or  two  apo.looks  now  as  if  it  had  been  a 


nme  so  complete  in  regard  to  the  structure  and  func 
tions  of  f'e  nervous  system  in  all  its  relations,  a 
subject  that,  in  many  respects,  is  one  of  the  most  difii- 
cult  of  all,  in  the  whnle  range  of  physiology,  upon 
which  to  produi-e  a  full  and  !^atisfactory  treatise  uf 
the  class  to  which  the  one  before  us  belongs.  The 
additions  by  the  American  editor  give  to  the  work  as 
it  is  a  considerable  value  beyond  that  of  the  last 
English  ediiion.  In  conclusion,  we  can  give  our  cor- 
dial recommendation  to  the  work  as  it  now  appears 
The  editors  have,  with  their  additions  to  the  only 
work  on  physiology  in  our  language  that,  in  the  full, 
est  sen^e  of  the  word,  is  the  production  of  a  philoso- 
pher as  well  as  a  physiologist,  brought  it  up  as  fully 
as  could  be  expected,  if  not  desired,  to  the  standard 
of  our  knowledge  of  its  subject  at  the  present  day. 
It  will  deservedly  maintain  the  place  it  has  always 
had  iu  the  favor  of  ihe  medical  profession. — Journ. 
of  Nervous  and  Mental  Duease,  April,  1S77. 

Such  enormous  advances  haverecentlybeen  madein 
our  physiological  knowledge,  that  what  was  perfectly 


received  and  established  fact  for  3'ears.  In  this  encj'- 
dopfedic  way  it  is  unrivalled.  Here,  as  it  seems  to 
us.  is  the  sreat  value  of  the  book:  one  is  safe  in  sending 
a  student  to  it  for  information  on  almost  any  given 
subject,  perfectly  certain  of  the  fulness  of  information 
it  will  convey,  and  well  satisfied  of  the  accuracy  with 
which  it  will  there  be  found  stated. — Lmtdon  Med. 
Times  and  Gazette,  Feb.  17, 1877. 

The  merits  of  "Carpenter's  Physiology"  are  sowidelj 
known  and  appreciated  that  we  need  only  allude  briefly 
to  the  fact  thai  in  the  latest  edition  will  be  found  a  com- 
prehensive embodiment  of  the  results  of  recent  physio- 
logical investigation.  Care  has  been  taken  to  preserve 
the  practical  character  of  the  original  work.  In  fact 
the  entire  work  has  been  brought  up  to  date,  and  bears 
evidence  of  the  amount  of  labor  that  has  been  bestowed 
upon  it  by  its  distinguished  editor,  Mr.  Henry  Power. 
The  -American  editor  has  made  the  latest  additions,  in 
order  fully  to  cover  the  time  that  has  elapsed  since  the 
last  English  edition. — N.  T.  Med.  Journal,  Jun.lS'l'i . 


F 


OSTER  [MICHAEL),  M.D.,  F.R.S., 

Pro/,  of  Physiolog-g  in  Cambridge  Univ  ,  England. 

TEXT-BOOK  OF  PHYSIOLOGY.     A  new  American,  from  the  third 

English  edition.  Edited  with  notes  and  additions  by  Edward  T.  Reichert,  M.D., 
Demonstrator  of  Experimental  Therapeutics  in  Univ.  of  Penna.  In  one  handsome  royal 
12mo.  volume  of  lOoO  pages,  with  259  illustrations.  Cloth,  $1  50.  Leather,  $2  00. 
(Just  Ready.) 

American  Editor's  Preface. 

The  high  reputation  acquired  on  both  sides  of  the  Atlantic  by  Dr.  Foster's  "Text-Book  on 
Physiology,"  as  a  lucid  exposition  of  functional  physiology,  in  its  most  modern  aspect,  has  seemed 
to  call  for  an  edition  more  thoroughly  adapted  to  the  wants  of  the  American  student.  The  plan 
of  the  author  has  presupposed  an  acquaintance  with  the  details  of  physiological  anatomj'  such  as 
the  student  is  accustomed  to  look  to  in  his  treatises  on  physiology.  The  absence  of  these 
details  has  rendered  many  parts  of  the  work  vague,  if  not  altogether  incomprehensible,  and  has 
therefore  proved  a  serious  drawback  to  the  usefulness  of  the  book  as  an  accompaniment  to  lec- 
tures on  physiology,  as  it  is  usually  taught  in  our  schools,  and  this  deficiency  the  editor  has 
endeavored  to  supply,  by  brief  notes  and  the  introduction  of  a  large  number  of  illustrations. 

The  almost  limitless  amount  of  material  accumulated  by  modern  research  has  rendered  di£B- 
cult  the  task  of  selection  and  compression,  without  exceedirg  the  reasonable  limits  r)f  a  conve- 
nient text-book.  In  his  selection  the  editor  has  been  guided  by  his  experience  in  the  wants  of 
students,  and  has  endeavored  merely  to  present,  in  the  most  concise  form,  such  facts  as  would  seem 
to  be  indispensable  to  a  correct  appreciation  of  the  structure  and  function  of  the  important 
organs.  In  accomplishing  this,  his  additions  have  considerably  exceeded  his  expectations, 
amounting  to  about  140  pages,  including  the  illustrations  which  have  been  increased  in  number 
from  72  to  259.  If  he  shall  thus  have  succeeded  in  rendering  this  admirable  work  better  fitted 
for  the  wants  of  the  American  student,  he  will  feel  abundantly  rewarded. 

Nothing  has  been  omitted  from  the  English  edition,  and  all  additions  have  been  distin- 
guished by  insertions  in  brackets  [ — ]. 

rhe  great  popularity  of  "Foster's   Text-book   of  ,  and  the  student,  at  the  outset,  will  have  to  make  up 


Physiology,"  both  in  England  and  ia  this  country 
renders  it  unnecessary  to  say  anything  further  re- 
garding its  merit.  We  shall,  therefore,  simply 
point  out  that,  in  the  Arnericau  edition,  numerous 
important  additions  have  been  made  to  the  text  of 
the  third  English  edition  whereby  the  usefulaess  of 
the  work  as  a  text-book  for  students  has  been  greatly 
increased.— P/ti/a.  Med.  and  Surg.  Reporter,  April 
21,18S0. 

Foster's  Physiology  is  a  most  excellent  book,  not 
only  for  the  student,  bat  especially  for  the  physician 
who  wishes  to  revise  and  increase  his  physiological 
knowledge.  The  style  of  the  author  is  clear,  his  ar- 
rangement and  classification  of  subjects  vtry  satis- 
factory, and  he  has  presented  in  this  volume  a  most 
valuable  exposition  of  physiology  as  now  known. — 
The  Am.  Practitioner,  April,  18S0. 

Every  sentence  shows  careful  and  mature  thooght. 


his  mind  that  Foster's  work  requires  study,  and  not 
simply  a  cursory  reading.  The  work  is  well  illus- 
trated, and  its  method  clear  and  logical,  and  emi- 
nently practical,  and  fully  up  to  the  present  ad- 
vanced status  of  this  moat  important  branch  of 
medicine.  Foster's  work  is  a  credit  to  his  scholar- 
ship and  research,  and  will  be  accepted  everywhere 
by  the  student  and  practitioneras  reliable  authority. 
It  should  be  in  the  hands  of  every  medical  student. 
—St.  Louie  Olin.  Record,  April,  1880. 

In  the  presentation  of  the  latest  and  the  most 
serviceable  facts  the  work  is  peculiarly  rich,  and 
the  author  is  also  decidedly  happy  in  his  freedom 
fr(im  tedium  or  useless  details,  and  omission  of  so 
very  little  that  a  book  for  students  needs  to  teach. 
The  style  is  scholarly,  and  the  volume  a  thoroughly 
welcome  one. — Cincinnati  Med.  Gaz.  and  Recorder, 
April,  1880. 


THE  SAME.     English  Student's  Edition,  without  notes  or  additions. 

one  small  12mo.  volume  of  804  pages  with  72  illustrations.     Cloth,  75  cents. 


In 


Henry  C,  Lea's  Son  &  Co.'s  Publications — (Physiology.,  Chemistry).   9 


PiALTON  {J.  C),  M.D., 

-*^  Professor  of  Physiology  in  the  College  of  Physieians  and  Surgeons,  New  Torlc.&c. 

A  TREATISE  ON  HUMAN  PHYSIOLOGY.    Designed  for  the  use 

of  Studentsand  Practitioners  of  Medicine.  Sixth  edition,  thoroughly  revised  and  enlarged, 
with  three  hundred  and  sixteen  illustrations  on  wood.  In  one  very  beautiful  ontavo  vol- 
ume, of  over  800  pages.    Cloth,  $5  50  ;  leather,  $6  50  f  half  Russia,  $7.     iJnst  Issued.) 


During  the  past  few  year.<  several  new  work.«on  phy- 
siology, and  new  editions  of  old  works,  baveappeared, 
eompetiiig  for  thefayor  of  the  medical  student,  but 
none  will  rival  this  new  edition  of  Dalton.  A.s  now  en- 
larged, it  will  be  found  also  to  be,  in  ;;eneral,  a  satisfac- 
tory work  of  reference  for  the  practitioner. — Chicayo 
Mpd.  Journ.  ind  Examiner,  J a,n.  1876. 

Prof.  Dalton  has  discussed  conflicting  theories  and 
conclusions  resarding  physiological  questions  with  a 
fairness,  a  fulness,  and  a  conciseness  which  lend  fresh- 
ness and  vi^or  to  the  entire  book.  But  his  discussions 
have  been  S"  guarded  by  a  refusal  of  admission  to  those 
speculative  and  theoretical  explanations,  which  al  best 
exist  in  the  mindsof  observers  themselves  as  only  pro- 
babilities, that  none  of  his  readers  need  he  led  into 
erave  errors  while  making  them  a  study. — The  Medical 
Record,  Feb.  19,  1876. 

The  revision  nfthis  great  work  has  broughtit  forward 
with  the  physiological  advances  of  the  day.  and  renders 
it,  as  it  has  ever  lieen,  the  finest  work  for  students  ex- 
tant,— Nashville  Jnurn.  of  Med.  and  Surg.,  Jan.  1876. 

For  clearness  and  perspicuity,  Daltoii's  Physiology 
commended  itself  to  the  student  years  ago.  and  was  a 
pleasant  relief  from  the  verbose  productions  which  it 
supplanted.  Physiolfigy  has,  however,  made  many  ad- 
vances since  then  — and  while  the  style  has  been  pre- 
served intact,  the  work  in  the  present  edition  has  been 
brought  up  fully  abreast  of  the  times.  Thenew  chemical 
notation  and  nomenclature  have  also  been  introduced 
into  the  present  edition.  Notwith.sianding  the  multi- 
plicity of  text-books  on  physiology. this  will  lose  none 


Dfits  old  time  popularity.  The  mechanical  execution 
)f  the  work  is  all  that  could  be  desired. — Peninsular 
Tournal  of  Medicine,  Dec.  1875. 

This  popular  texi-book  on  physiology  comes  to  us  in 
its  sixth  edition  with  the  addition  of  about  fifty  percent, 
of  new  matter,  chiefly  in  the  departments  of  patho- 
logical chemistry  and  the  nervous  systtm.  where  the 
principal  advances  have  been  realized.  With  so  tho- 
rough revision  and  additions,  that  keepthe  work  well 
up  to  the  times,  its  continued  p'^pularity  may  be  confi- 
dently oredicted,  notwithstanding  the  competition  it 
may  encounter.  The  publisher's  work  is  admirably 
done. — St.  Louis  Meil.and  Surg .  Jnurn  ,  Dec.  1875. 

We  heartily  welcome  this,  the  sixth  edition  of  this 
admirablel^ext  book,  than  which  there  are  none  of  equal 
brevitv  more  valuable.  It  iscordially  recommended  by 
the  Professor  of  Physiology  in  the  University  of  Louisi- 
ana, as  by  all  competent  teachers  in  the  United  States, 
and  wherever  the  Knglish  language  is  read,  this  book 
has  been  appreciated.  The  present  edition,  with  its  316 
admirably  executed  illustrations,  has  been  carefully 
revised  and  very  much  enlarged,  although  its  bulkdoes 
not  seem  perceptibly  increased. — New  Orleans  Medical 
and  SurgicalJniirnal,  .March,  1876. 

The  present  edition  is  very  much  superior  to  every 
other,  not  only  in  that  it  brings  the  subject  up  to  the 
times,  but  that  it  does  so  more  fully  and  satisfactorily 
than  any  previous  edition  Takeitaltoeietherit  remains 
in  our  hum  hie  opinion,  thebest  text  hook  on  physiology 
in  any  land  or  language. — The  Clinic,  Sot .  6,  1875. 


G 


REENE  [WILLIAM  H.),  M.D., 

Demonstrotor  of  Chemistry  in  Med.  Dept  ,  Univ.  of  Panna. 

A  MANUAL  OF  MEDICAL  CHEMISTRY.    For  the  Use  of  Students. 

Bnsed  upon  Bowman's  Medical    Chemistry.     In   one  royal  12mo.  volume  of  312  pages. 
With  illustrations.     Cloth,  $1  75.     (Just  Issued.) 


It  is  well  written,  and  gives  the  latest  view^  on 
vital  chemistry,  a  .subject  with  which  m  )st  phy-i- 
ciaus  are  not  sufficiently  familiar.  To  those  who 
may  wish  to  improve  their  knowledge  in  that  direc 


The  little  work  before  us  is  one  which  we  think 
will  be  studied  with  pleasure  aad  prufit  The  de- 
sciintions,  though  brief,  are  clear,  and  in  most  cases 
sufficient  for  the  purpose      This  book  will,  iu  nearly 


tion,  we  can  heartily  rrcorameud  this  work  as  being    all   case',    meet  general   approval. — Am.  Journ.  of 
worthy  ofa  careful  perusal. — Phila.  Med.  and  Surg.     Pharmacy,  April,  1880. 
Reporter,  A\i\\\'2,i,\SS(l. 


ftLASSEN  [ALEXANDER), 

^-^  Profes.oor  in  the  Royal  Polytechnic  School,  Aix  la-Chapelle. 

ELEMENTARY^   QUANTITATIVE    ANALYSIS.     Translated  with 

notes   and  additions  by  Edgar  F.  S.mith,   Ph.D.,  Assistant  Prof,  of  Chemistry  in  the 
Towne  Scientific  School,  Univ.  of  Penna.     In  one  handsome  royal  12mo.  volume,  of  324 
pages,  with  illustrations;  cloth,  $2  00.     (Just  Ready.) 
It  is  probably  the  best  minual  of  an  elementary  ;  advancing  to  the  analysis  of  minerals  and  such  pro- 
nature  extant,  insomuch  as  its  methods  are  the  best.  ,  ducts  as  are  met  with  in  applied  chemistry.     It  is 
It   teaches  by  examples,   commencing   with   single  i  an  iadispeosable  book  for  stadeats  in  chemistry. — 
determinations,  followed  by  separations,  and  then  !  Boston  -jotirn.  of  Chemistry,  Oct.  1878. 

ryA LLOWAY  [ROBERT],  F. C.S., 

^-^  Prof  of  Applied  Chemi.^try  in  the  Royal  College  of  Science  for  Ireland,  etc. 

A  MANUAL  OP  QUALITATIVE  ANALYSIS.  From  the  Fifth  Lon- 
don Edition.  In  one  neat  royal  12mo.  volume,  with  illustrations;  cloth,  $2  75.  (Lately 
Issued.) 

J^EMSEN[IRA),  M.D.,  Pli^, 

Professor  of  Chemistry  in  the -Tohns  Hopkins  University,  Baltimore. 

PRINCIPLES  OF  THEORETICAL  CHK.VHSTRY,  with  special  reference 

to  the  Constitution  of  Chemical  Compounds.   In  one  handsome  royal  12mo.  vol.  of  over 
232  pages:  cloth,  $1  50.     (Just  Issued.) 


BOWMAN'S  INTRODUCTION  TO  PRACTICAL 
CHEMISTRY,  INCLt'DING  ANALYSIS.  Sixth 
American,  from  the  sixth  and  revised  London  edi- 
tion. With  numerous  illustrations.  In  one  neat 
vol.,  royal  12mo.,  cloth,  $2  2.5. 

WOHLEPv  AND  FITTIG'S  OUTLINES  OF  ORGANIC 
CHEMISTRY.  Translated  with  additionsfrom  the 
Eighth  German  Edition.  By  Ika  Re.msen.  M  D  , 
Ph.D.,  Prof,  of  Chemistry  and  Physics  in  Williams 


College,  Mass.     In  one  volume,  royal  12mo.  of  550 
pp  ,  cloth,  $3. 

LEHMANK'S  MANUAL  OF  CHEMICAL  PHYSIOL- 
OGY. Translated  from  the  German,  with  Notes 
and  Additions,  by  J.  Chesto.v  Morris,  M.D.  With 
illustrations  on  wood.  In  one  octavo  volume  of 
3.36  pages.     Cloth,  $2  25. 

I  LEHMANN'S  PHYSIOLOGICAL  CHEMISTRY.  Com- 
I      plete  in  two  large  octavo  volumes  of  1200  pages, 
with  200  illnstratiiins!  cloth    ilifi 


10 


Henry  C.  Lea's  Son  &  Co.'s  Publications — {Chemistry). 


pOWNES  [GEORGE),  Ph.D. 

A  MANUAL  OF  ELEMENTARY  CHEMISTRY;  Theoretical  and 

Practical.    Revised  and  corrected  by  Henry  Watts,  B.  A.,  F.R.S.,  author  of  "A  Diction- 
ary of  Chemistry,"  etc.    With  a  colored  plate,  and  one  hundred  and  seventy-seven  illus- 
trations.   A  new  American,  from  th<  twelfth  and  enlarged  London  edition.     Edited  by 
Robert  Bridges,   M.D.       In   one  large   royal  12mo.   volume,   of  over  1000  pages; 
cloth,  $2  75  ;  leather,  $3  25.     (J^ist  Issued.) 
Two  careful  revisions  by  Mr.  Watts,  since  the  appearance  of  the  last  American  edition  of 
"Fownes,"  have  so  enlarged  the  work  that  in  England  it  has  been  divided  into  two  volumes.    In 
reprinting  it,  by  the  use  of  a  small  and  exceedinglj' clear  type,  cast  for  the  purpose,  it  has  been 
found  possible  to  comprise  the  whole,  without  omission,  in  one  volume,  not  unhandy  for  study  and 
reference.   The  enlargement  of  the  work  has  induced  the  American  Editor  to  confine  his  additions 
to  the  narrowest  compass,  and  he  has  accordingly  inserted  only  such  discoveries  as  have  been  an- 
nounced since  the  very  recent  appearance  of  the  work  in  England,  and  has  added  the  standards 
in  popular  use  to  the  Decimal  and  Centigrade  systems  employed  in  the  original. 

Among  the  additions  to  this  edition  will  be  found  a  very  handsome  colored  plate,  representing 
a  number  of  spectra  in  the  spectroscope.  Every  care  has  been  taken  in  the  typographical  execu- 
tion to  render  the  volume  worthy  in  every  respect  of  its  high  reputation  and  extended  use,  and 
though  it  has  been  enlarged  by  more  than  one  hundred  and  fifty  pages,  its  very  moderate  price 
will  still  maintain  it  as  one  of  the  cheapest  volumes  accessible  to  the  chemical  student. 


This  work,  inorganic  and  organic,  is  complete  lu 
one  conveaieut  volume.  In  its  earliest  editions  it 
was  fully  up  to  the  latest  advancements  and  theo- 
ries of  that  time.  In  its  present  form,  it  presents, 
in  a  remarkably  convenient  and  satisfactory  man- 
ner, the  principles  and  leading  facts  of  the  chemistry 
of  to-d(ty.  Concerning  the  manner  in  which  the 
various  subjects  are  treated,  much  deserves  to  be 
said,  and  mostly,  too,  in  praise  of  the  book.  A  re- 
view of  such  a  work  ai'  Fownes's  Chemis-try  within 
the  limits  of  a  book-notice  for  a  medical  weekly  is 
simply  out  of  the  question. — Cineinnnti  Lancet  and 
Olinic,  Dpc.  14,  1S7S. 

When  we  state  that,  in  our  opinion,  the  present 
edition  sustains  in  every  respect  the  high  reputation 
which  its  predecessors  have  acquired  and  enjoyed, 
we  express  therewith  our  full  belief  in  its  intrinsic 
value  as  a  text-book  and  work  of  reference. — Am. 
Journ.  of  Pharm.,  Aug.  1878. 

The  conscientious  care  which  has  been  bestowed 
upon  it  l)y  the  American  and  English  editors  renders 
it  still,  perhaps,  the  best  book  for  the  student  and  the 
practitiiiner  who  would  keep  alive  the  acquisitions 
of  his  student  days.    It  has,  indeed,  reached  a  some- 


what formidable  magnitude  with  its  more  than  a 
thousand  pages,  but  with  less  than  this  no  fair  repre- 
sentation of  chemistry  as  it  now  is  can  be  given.  The 
type  is  small  but  very  clear,  and  the  sections  are  very 
lucidly  arranged  to  facilitate  study  and  reference.— 
Mtd.  and  Surg.  Reporter,  Aug  3,  1878. 

The  work  is  too  well  known  to  American  students 
to  need  any  extended  notice;  sutiice  it  to  say  that 
the  revision  by  the  English  editor  has  been  faithfully 
done,  and  that  Professor  Bridges  has  added  some 
fresh  and  valuable  matter,  especially  in  the  inor- 
ganic chemistry.  The  book  has  always  been  a  fa- 
vorite in  this  country,  and  in  its  new  shape  bids 
fair  to  retain  all  its  former  prestige. — Boston  Jour, 
of  Chumistry ,  Aag.  1878. 

It  will  be  entirely  unnecessary  for  ns  to  make  any 
remarks  relating  tothe  general  characterof  Fownes' 
Manual.  For  over  twenty  years  it  has  held  the  fore- 
most place  as  a  text-book,  and  the  elaborate  and 
thorough  revisions  which  have  been  made  from  time 
to  timeleavelittlechance  for  any  wideawakerival  to 
step  before  ii.— Canadian  Pharm.  Jour.,  Aug.  1878. 

As  a  manual  of  chemistry  it  is  without  a  superior 
in  the  language.— J[/d.  Med.  Jour.,  Aug.  1878. 


J  TTFIELD  {JOHN),  Ph.D., 

*^  Pro/e.i»or  of  Practical  Chemistry  to  the  Pharmaceutical  Society  of  Great  Britain,  &e. 

CHEMISTRY,  GENERAL,  MEDICAL,  AND  PHARMACEUTICAL; 

including  the  Chemistry  of  the  U.  S.  Pharmacoiioeia.  A  Manual  of  the  General  Principles 
of  the  Science,  and  their  Application  to  Medicine  andPharmacy.  Eighth  editionrevised 
by  the  author.  In  one  handsome  royal  12mo.  volume  of  700  pages,  with  illustrations. 
Cloth,  $2  50  ;  leather,  $3  00.      (Jiist  Ready.) 

We   have    repeatedly   expressed    our  favorable  [  of    chemistry  in   all  the   medical   colleges  in  the 
opinion  of  this  work,  and  on  the  appearance  of  a  |  United  States.     The  present  edition  contains  snch 


new  edition  of  it,  little  remains  for  us  to  say,  ex- 
cept, that  we  expect  this  eighth  edition  to  be  as 
indispensable  to  us  as  the  seventh  and  previous 
editions  have  been.  While  the  general  plan  and 
arrangement  have  been  adhered  to,  new  matter 
has  been  added  covering  the  observations  made 
since  the  former  edition  The  present  differs  from 
the  preceding  one  chiefly  in  these  alterations  and 
in  about  ten  piges  of  useful  tables  added  in  the 
appendix  —.4wi.  Jour,  of  Pharmacy,  May,  1S79. 

A  standard  work  like  Attfleld's  Chemistry  need 
only  be  mentioned  by  its  name,  withnut  further 
comments  The  present  edition  contains  such  al 
terations  and   additions  as  seemed    neceisary  for 


alterations  and  additions  as  seemed  necessary  for 
the  demonstration  of  the  latest  developments  of 
chemical  principles,  and  the  latesi  applications  of 
chemistry  to  pharmacy.  It  is  scarcely  necessary 
for  us  to  say  that  it  exhibits  chemistry  in  its  pre- 
sent advanced  state. — Cincinnati  Medical  News, 
April,  1879. 

The  popularity  which  this  work  has  enjoyed  is 
owing  to  the  origical  and  clear  disposition  of  the 
facts  of  the  science,  the  accuracy  of  the  details,  and 
the  omission  of  much  which  freights  many  treatises 
hwavily  without  bringing  corresponding  instruction 
to  the  reader.  Dr.  Attfield  writes  for  students,  and 
primarily  for  medical  students;  he  always  has  an 


the  demonstration   of  the  latest  developments  of  |  eye  to  the  pharmaiopceia  and  its  ofBcinal  prepara 


ehcmical  principles,  and  the  latest  applications  of 
chemistry  to  pharmacy.  The  author  has  bestowed 
arduous  labor  on  the  revision,  and  the  extent  of 
the  information  thus  introduced  may  be  estimated 
from  the  fact  that  the  index  contains  three  hun- 
dred new  references  relating  to  additional  mater- 
ial.—7)rj/f?£rj»<*'  Circular  and  Chemical  Oazette, 
May,  1879. 

This  very  popular  and  meritorious  work  has 
now  reached  its  eighth  edition,  which  fact  speaks 
in  the  highest  terms  in  commendation  of  its  excel- 
lence.    It  has  now  become  the  principal  text-book 


tions;  and  he  is  continually  putting  the  matter  in 
the  text  so  that  it  responds  to  the  questions  with 
which  each  section  is  provided.  Thus  the  student 
learns  easily,  and  can  always  refresh  and  test  bis 
knowledge. — Med  and  Surg.  Reporter,  April  19, '7.9. 
We  noticed  only  about  two  vears  and  a  half  ago 
the  publication  of  the  preceding  edition,  and  re- 
marked upon  the  exceptionally  valuable  character 
of  the  work.  The  work  now  iaclndes  the  whole  of 
t  he  chemistry  of  the  phai  macopoeia  of  the  Dniled 
States,  Great  Britain,  and  India. — New  Remedies, 
May,  1S79. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Chemistry).  11 


ULOXAM  iC.L.), 

J-'  ProfeKsor  of  Ohemittry  in  King^s  College,  London. 

CHEMISTRY,  INORGANIC  AND  ORGANIC.    From  the  Second  Lon- 


don  Edition.     In  one  very  handsome  octa 
trations.     Cloth,  $4  00;  leather,  $5  00. 

We  havein  this  work  a  complete  and  most  excel- 
len-t  text-book  for  the  use  of  fichools,  and  can  heart- 
ily recommend  it  as  such. — Boston  Med.  and  Surg. 
Journ.,  May  '28,  187-1. 

The  above  is  the  titleof  a  work  which  we  can  most 
conscieniiouBly  recommend  to  students  of  chemis- 
try. It  is  as  easy  as  a  work  on  chemistry  could  be 
made,  at  thesametime  that  it  presents  a  full  account 
of thatscience  as  it  now  stands.  We  have  spoken 
of  the  work  as  admirably  adapted  to  the  wants  of 
students  ;  it  is  quite  as  well  suited  to  the  require- 
ments of  practitioners  who  wish  to  review  their 
cJiemistry,  or  have  occasion  to  refresh  their  memo- 
ries on  any  point  relating  to  it.  In  a  word,  it  is  a 
book  to  be  read  by  all  who  wish  to  know  wliat  is 
thechemistry  of  the  presentday. — American  Prac- 
titioner, Nov.  1873. 


vo  volume,  of  700  pagee,  with  about  300  illus- 

(Lalely  Issiied.) 

It  would  be  difficult  for  a  practical  chemist  and 
teacher  to  find  any  material  fault  with  this  most  ad- 
miriible  treatise.  The  author  has  given  us  almost  a 
C)  clopzedia  wilhin  the  limits  of  aconvenient  volume, 
and  has  done  so  without  penning  ihe  useless  para- 
graphs too  commonly  making  up  a  great  part  of  the 
bulk  of  many  cumbrous  works.  The  progressive 
scientist  is  not  disappointed  when  he  looks  for  the 
reeord  of  new  and  valuable  processes  and  discover- 
ies, while  the  cautious  conservative  does  not  find  its 
pages  monopolized  by  uncertain  theories  and  specu- 
lations. A  peculiar  point  of  excellence  is  the  crys- 
talliied  form  of  expression  in  which  great  truths  are 
expressed  in  very  short  paragra  phs.  One  is  surprised 
at  the  brief  space  allotted  to  an  important  topic,  and 
yet,  after  reading  it,  he  feels  that  little,  if  any  more 
should  have  been  said.  Altogetlier,  it  is  seldom  yoa 
see  a  text-book  so  nearly  faultless.  —  Cincinnati 
Lancet  Nov.  1873. 


C' 


'LOWES  (FRANK),  D.Sc,  London. 

Senior  Scienee-  Maiter  at  the  High  School,  Newcastle-under  Lyme,  etc. 

AN  ELEMENTARY  TREATISE  ON  PRACTICAL  CHEMISTRY 

AND  QUALITATIVE  INORGANIC  ANALYSIS.  Specially  adapted  for  Use  in  the 
Lalioratorieg  of  Schools  and  Colleges  and  by  Beginners.  From  the  Second  and  Revised 
English  Edition,  with  about  fifty  illustrations  on  wood.  In  one  very  handsome  royal 
12mo.  volume  of  372  pages  :  cloth,  $2  60.      {JiiH  Issued.) 


It  is  short,  concise,  and  eminently  practical.  We 
tMfrefore  heartily  commendit  to  students,  and  espe- 
cially to  those  who  are  obliged  to  dispense  with  a 
master.  Of  course,  a  teacher  is  in  every  way  desi- 
rable, but  a  good  degree  of  technical  skilland  prac- 
tical knowledge  can  be  attained  with  no  other 
instructor  than  the  very  valuable  handbook  now 
under  consideration. — St.  Louis  Clin.  Reeord,  Oct. 
1877. 

The  work  is  so  written  and  arranged  that  it  can  be 
comprehendedby  the  student  without  a  teacher,  and    Yf~-,'otj 
the  descriptions  and  directions  forthe  various  work    '■°'  '°' '• 


are  so  simple,  and  yet  concise,  as  to  be  interesting 
and  intellig'ble.  The  wqrk  is  unincumbered  with 
theoretical  deduetions,  dealing  wholly  with  the 
practical  matter,  which  it  is  theaimofthis  compre- 
hensive text-book  to  impart.  The  accuracy  of  the 
analytical  methods  are  vouched  for  from  the  fact 
that  they  have  all  been  worked  through  by  the 
author  and  the  members  of  his  class,  from  the 
printed  text.  We  can  heartily  recommend  the  work 
to  the  student  of  chemistry  as  being  a  reliable  and 
comprehensive  one. — Druggists'  Advertiser,  Oct. 


KNA-PP'S  TECHNOLOGY;  or  Chemistry  Applied  to 
the  Arts,  and  to  Manufactures.  With  American 
additions  by  Prof.  Walter  R.  Johnson.     In  two 


very  handsome  octavo  volumes,  with  .500  wood 
engravings,  cloth,  |;6  00. 


yARRISH  (EDWARD), 

Late  Professor  of  Materia  Mediea  in  the  Philadelphia  College  of  Pharmacy. 

A  TREATISE  ON  PHARMACY.     Designed  as  a  Text-Book  for  the 

Student,  and  as  a  Guide  for  the  Physician  and  Pharmaceutist.  With  many  Formulae  and 
Prescriptions.  Fourth  Edition,  thoroughly  revised,  by  Thomas  S.  Wiegand.  In  one 
handsome  octavo  volume  of  977  pages,  with  280  illustrations;  cloth.  $5  50  ;  leather,  $6  50; 
half  Russia,  $7.      (Lately  Issved.) 

the  work,  not  only  to  pharmacists,  but  also  to  the 
multitude  of  medical  practitioners  who  are  obliged 
to  compound  their  own  medicines.  It  will  ever  hold 
an  honored  place  on  our  own  bookshelves. — Dublin 
Med.  Press  and  Circular,  Aug.  12,  1874. 


Of  Dr.  Parrish's  great  work  on  pharmacy  it  only 
retirains  to  be  said  thai  the  editor  has  accomplislied 
his  work  so  well  as  to  maintain,  in  this  fourth  edi- 
tion, the  high  standard  of  excellence  which  it  had 
attained  in  previous  editions,  under  the  editorship  of 
its  accomplished  author.  This  has  not  been  accom- 
plished without  much  labor, and  many  additions  and 
improvements,  involving  changes  in  the  arrange- 
mentof  the  several  parts  of  the  work,  and  the  addi- 
tion of  much  new  matter.  With  the  modificatious 
thus  effected  it  constitutes,  as  now  presented,  a  com- 
pendium of  the  science  and  art  indispensable  to  the 
pharmacist,  and  of  the  utmost  value  to  every 
practilioner  of  medicine  desirous  of  familiarizing 
himself  with  the  pharmaceutical  preparation  of  the 
articles  which  he  prescribes  for  his  patients. — Chi- 
cago Med.  J'ottrn.,  July,  1874. 

The  work  is  eminently  practical,  and  has  the  rare 
merit  of  being  readable  and  interesting,  while  it  pre- 
serves astrictly  scienlificcharacter.  The  whole  work 
reflects  the  greatest  credit  on  author,  editor  and  pub 
Usher.  It  will  convey  someideaof  the  liberality  which 
has  been  bestowed  upon  its  production  when  we  men- 
tion that  there  are  nolescthan  2S0  carefully  executed 
Illustrations.  In  conclusion,  we  heartily  recommend 


We  expressed  our  opinion  of  a  former  edition  in 
terras  of  unqualified  praise,  and  we  are  in  no  mood 
to  detract  from  that  opinion  in  reference  to  the  pre- 
sent edition,  the  preparation  of  which  has  fallen  into 
competent  hands.  It  is  a  book  with  which  no  pharma- 
cist can  dispense,  and  from  which  no  physician  can 
fail  to  derive  much  information  of  value  to  him  in 
practice. — Pacific  Med.  and  Surg.  Journ.,  June, '74. 

Perhaps  one,  if  not  the  most  important  book  upon 
pharmacy  which  has  appeared  in  the  English  lan- 
guage has  emanated  from  the  transatlantic  press. 
"  Parrish's  Pharmacy"  is  a  well-known  work  on  this 
side  of  the  water,  and  the  factshows  us  that  a  really 
useful  work  neverbeeomes  merely  local  in  its  fame. 
Thanks  to  the  judicious  editing  of  Mr.  Wiegand,  the 
poBthuraous  edition  of"Parrish"  has  been  saved  to 
the  public  with  all  the  mature  experience  of  its  au- 
thor, and  perhaps  none  the  worse  for  a  dash  of  new 
blood. — Land.  Pharm.  Journal,  Oct.  17,  1874. 


12  Henry  C.  Lea's  Son  <fe  Co.'s  Publications — {Mat.  Med.  and  Therap.). 


pfARQVHARSON  {ROBERT),  M.D., 

Lecturer  on  M/Uerin  Medica  at  St.  Mary' s  Hospital  Medical  School. 

A  GUIDE  TO  THERAPEUTICS  AND  MATERIA  MEDICA.     Se- 

cond  American  edition,  revised  by  the  Author.  Enlarged  and  adapted  to  the  U.  S. 
Pharmacopoeia.  By  Frank  Woodbury,  M.D.  In  one  neat  royal  12mo.  volume  of  498 
pages:  cloth,  $2.25.      {Just  Ready.) 

copious  notes  have  been  introdnced,  erabodying  the 
latest  revision  of  t*e  Pharmacopoeia,  together  vri'h 
the  antidotes  to  the  more  promiuent  poisons,  and 
such  of  the  newer  remedial  ageut!>  as  seemed  neces- 
sary to  the  completeness  of  the  work.  Tables  of 
weights  and  measures,  and  a  good  alphabetical  in- 
dex end  the  volume. — Drugyists'  Circular  and 
Chemical  Gazette,  June,  1S79. 

It  is  a  pleasure  to  think  that  the  rapidity  with 
which  a  second  edition  is  demanded  may  be  taken 
as  an  indication  that  the  sen.se  of  appreciation  of  the 
value  of  reliable  information  regarding  the  use  of 
remedies!^  notentirelj  overwhelmed  in  the  cultiva- 
tion of  pathological  ."tudies,  cliarac  I  eristic  of  the  pre- 
sent day.  This  work  certainly  merits  the  success  it 
has  so  quickly  achieved. — New  Remedies,  July,  '79. 


The  appearance  of  a  new  edition  of  this  conve- 
nient and  handy  book  in  less  than  two  years  may 
certainly  be  taken  as  an  indication  of  its  nsefnl 
ness.  Its  convenient  arrangement,  and  its  terse- 
ness, and,  at  the  same  time,  comoleteness  of  the 
information  given,  make  it  a  handy  book  of  refer- 
ence.— Am.  Journ.  of  Pharmaty,  June,  1879. 

This  work  contains  in  moderate  compass  such 
well-digested  fact?  concerning  the  physiologiral 
and  therapeutical  action  of  remedies  as  are  reason- 
ably established  up  to  the  present  time.  By  a  con- 
venient arrangement  the  corresponding  effects  of 
each  article  in  health  and  disease  are  presented  in 
parallel  columns,  not  only  rendering  reference 
easier,  but  also  impressing  the  facts  more  strongly 
upon  the  mind  of  the  reader.  The  book  has  been 
adapted  to  the  wants  of  the  American  student,  and 


(^TILLE  {ALFRED),  M.D., 

Professor  of  Theory  and  Practice  of  Medicine  in  the  University  of  Penna . 

THERAPEUTICS  AND  MATERIA  MEDICA  ;  a  Systematic  Treatise 

on  the  Action  and  Uses  of  Medicinal  Agents,  including  their  Description  and  History. 
Fourth  edition,  revised  and  enlarged.  In  two  large  and  handsome  8vo .  vols,  of  about  2000 
pages.     Cloth,  $10;  leather,  $12;  half  Russia,  $13.     (Lately  Issued.) 


It  is  unnecessary  to  do  much  more  than  to  an- 
nounce the  appearance  of  the  fourth  edition  of  this 
well  known  and  exc«llent  work. — Brit,  and  For. 
Med.-Chir.  Review,  Oct  187.5. 

For  all  who  desire  a  complete  work  on  therapeutics 
and  materia  medicafor  reference,  iu  ca.se^iuvulving 
medico-legal  questions,  as  well  as  for  information 
concerning  remedial  agents,  Dr.  Still6"s  is  "par  ex- 
cellence'' the  work.  The  work  being  out  of  print,  by 
the  exhaustion  of  former  editions,  the  author  has  laid 
the  profe.-^sion  under  renewed  obligations,  by  the 
careful  revision,  Important  additions,  nnd  timely  re 
issuing  a  work  not  exactly  supplemented  by  any 
other  in  the  English  language,  if  in  any  language. 
The  mechanical  execution  handsomely  sustains  the 
well-known  skill  and  good  taste  of  the  publi.sher. — 
St.  Louis  Med.  and  Surg.  Journal,  Dec   1874. 

From  the  publication  of  the  first  edition  "Stmt's 
Therapeutics"  has  been  one  of  the  classics;  its  ab- 
sence from  our  librariex  would  create  a  vacuum 
which  could  be  filled  by  no  other  work  in  the  lan- 
guage, and  its  presence  supplies,  in  the  two  volumes 


of  the  present  edition,  a  whole  cyclopsedia  of  thera- 
peutics.—  Chicago  Medical  Joxci-nal,  Feb.  1S75. 

The  rapid  exhaustion  ofthree  editions  and  the  uni- 
ver-sal  favor  with  which  the  work  has  been  received 
by  the  medical  profession,  are  sufiicient  proof  of  its 
excellence  as  a  repertory  of  practical  and  useful  in- 
formation for  the  physician.  The  edition  before  ue 
fully  sustains  this  verdict,  as  the  work  has  been  care- 
fully revised  and  in  some  portions  rewritten,  brrng- 
ing  it  up  to  the  present  time  by  the  admission  of 
chloral  and  croton-chloral,  nitrite  of  amyl,  bichlo- 
ride of  methylene,  methylic  ether,  lithium  com- 
pounds, gelsemiuum,  and  other  remedies. — Am. 
Journ.  of  Pharmacy,  Feb.  1S75. 

We  can  hardly  admit  that  it  has  a  rival  in  the 
multitade  of  its  citiitinns  and  the  fulness  of  its  re- 
search into  clinical  histories,  and  we  must  assign  it 
a  )>lace  in  the  physician's  library;  not,  indeed,  as 
fully  representing  the  present  siate  of  knowledge  in 
pharmacodynamics,  but  as  by  far  the  most  complete 
treatise  upon  the  clinical  and  practical  side  of  the 
question. — Boston  Med.  and.  Surg.  Journal,  Nov.  5, 
1874. 


/GRIFFITH  {ROBERT  E.),  M.D. 

A  UNIVERSAL  FORMULARY,  Containing  the  Methods  ofPrepar- 

ing  and  Administering  Officinal  and  other  Medicines.  The  whole  adapted  to  Phy&iciars  and 
Pharmaceutists.  Third  edition,  thoroughly  revised,  with  numerous  additions,  b)  John  M. 
Maisch,  Professor  of  Materia  Medica  in  the  Philadelphia  College  of  Pharmacy.  In  one  large 
andhandsome  octavovolumeof  aboutSOOpp.,  cl.,  $450;  leather,  $5  50.  {Lately  Issued.) 


To  the  druggist  a  good  formulary  is  simply  indis- 
pensable, and  perhaps  no  formulary  has  been  more 
extensively  used  than  the  well-known  work  before 
as.  Many  physicians  have  toofllciate,  also,  as  drug- 
gists. This  is  true  especially  of  the  country  pliysi« 
cian,  and  a  work  which  shall  teach  him  the  inenn.'^ 
by  which  to  administer  or  combine  hi>*  remedies  in 
the  most  efficacious  and  pleasant  manner,  will  al- 
ways hold  its  place  upon  his  shelf  A  formulary  of 
this  kind  is  of  benefit  also  to  the  city  physician  in 
largest  practice.— Oinefnnnrti  Olinic,  Feb.  21.  1874. 


A  more  complete  formulary  than  it  is  in  its  pres- 
ent form  the  pharmacist  or  physician  could  hardfy 
desire.  To  the  first  some  such  work  is  indispeni-a- 
ble,  and  it  is  hardly  les.s  essential  to  the  [iractilioner 
who  compounds  his  own  medicines.  Much  of  what 
is  contained  in  the  introduction  ought  to  be  com- 
mitted to  memory  by  every  student  of  medicine. 
As  a  help  to  physicians  it  will  be  found  invaluable, 
and  doubtless  will  make  its  way  into  libraries  not 
already  supplied  with  a  standard  work  of  the  kind. 
—  The  American  Practitioner,  Louisville,  July,  '74. 


CHKISTISON'S  DISPENSATORY.  With  copions ad- 
ditions, and  '213  large  wood  engravings  By  R. 
EoLERFiRiD  Griffith,  M.D.  One  vol.  8vo.,  pp. 
1000,  cloth.    $4  00. 


CARPENTER'S  PRIZE  ESSAY  ON  THE  USE  OF 
Alcoholic  Liquors  in  Health  and  Disease.  New 
edition,  with  a  Preface  by  D.  F.  Condib.  M.D.,and 
explanationsof  scientiflcwords.  In  oneneat]2mo. 
volume,  pp.  178,  cloth.    60  cents. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — {Mat.  Med.and  Therap.).  13 
liJTILLE  {ALFRED),  31.  D.,  LL.D.,  and  JlfAISCH  (JOHN  M.).  Ph.D., 

A3        Prof  of  Theory  and  Praotic  of  Medicine  J-f-L        Prof,  of  Mat.  Med.  and  Bot.  in  Phila 


and  of  Clinical  Med.  in  Univ.  of  Pa. 


Coll.  Phnrmricy.  Si-cy  to  the  American 
Pharmaceutica I  Ax-^ocialion. 


THE   NATIONAL  DISPENSATORY:  Containitifr  the  Natural  History, 

Chemistry,  Pharmacy,  Actions  and  Uses  of  Medicines,  including  those  recoofnized  in 
the  Pharmacopoeias  of  the  United  States,  Great  Britain,  and  Germany,  with  numer- 
ous references  to  the  French  Codex.  Second  edition,  thoroughly  revised,  with  numerous 
additions.  In  one  very  handsome  octavo  volume  of  1692  pastes, with  2.39  illustrations. 
E.Klra  cloth,  $6  75;  leather,  raised  bands,  $7  50;  half  Russia,  raised  bands  and  open 
back,  $8  25.      {Now  Ready  ) 

Preface  to  the  Second  Edition. 

The  demand  which  has  exhausted  in  a  few  months  an  unusually  large  edition  of  the  National 
Dispensatory  is  doubly  gratifying  to  the  nuthors,  as  showing  that  they  were  correct  in  th'nking 
that  the  want  of  such  a  work  was  felt  by  the  medical  and  pharmaceutical  professions,  and  that 
their  efforts  to  supply  that  want  have  been  acceptable.  This  appreciation  of  their  labors  has 
stimulated  them  in  the  revision  to  render  the  volume  more  worthy  of  the  very  marked  favor 
with  which  it  has  been  received.  The  first  edition  of  a  work  of  vueh  magnitude  mu«t  necessarily 
be  more  or  less  imperfect  ;  and  thouijh  but  litt'e  that  is  new  and  important  has  been  brought 
to  light  in  the  short  interval  since  its  publication,  yet  the  length  of  time  during  which  it  was 
passing  through  the  press  rendered  the  earlier  portions  more  in  arrears  than  the  la'er.  The 
opportunity  for  a  revision  has  enabled  thp  authors  to  scrutinize  the  work  as  a  whole,  and  to 
introduce  alterations  .-ind  additions  whereve  •  there  has  seemed  to  be  occasion  for  improve- 
ment or  greater  completeness.  The  principal  changes  to  be  noted  are  the  introduction  of  seve- 
ral drugs  under  separate  headings,  and  of  a  large  number  of  drugs,  chemioaJs,  and  pharma- 
ceutical preparations  classified  as  allied  drugs  and  preparations  under  the  heading  of  more 
important  or  better  known  articles  :  these  additions  comprise  in  part  nearly  the  entire  German 
Pharmacopoeia  and  numerous  articles  from  the  French  Codex.  All  new  investigations  which 
came  to  the  authors'  notice  up  to  the  time  of  publication   have  received  due  coosideration. 

The  series  of  illustrations  has  undergone  a  corresponding  thorough  revision.  A  number  have 
been  added,  and  still  more  have  been  substituted  for  such  as  were  deemed  less  satisfactory. 

The  new  matter  embraced  in  the  text  is  equal  to  nearly  one  h mdred  pages  of  the  first  edition. 
Considerable  as  are  these  changes  as  a  whole,  they  have  been  accommodated  by  an  enlargement 
of  the  page  without  increasing  unduly  the  size  of  the  volume. 

While  numerous  additions  have  been  ma(?e  to  the  sections  which  relate  to  the  physiological 
action  of  medicines  and  their  use  in  the  treatment  of  dista^e,  great  care  has  been  taktn  to 
make  them  as  concise  as  was  possible  without  rendering  them  incomplete  or  obscure.  The 
doses  have  been  expressed  in  the  terms  both  of  troy  weight  and  of  the  metrical  system,  for  the 
purpose  of  mak'ng  those  who  employ  the  Dispensatory  familiar  with  the  latter,  and  paving  the 
way  for  its  introduction  into  general  use. 

The  Therapeutical  Index  has  been  extended  by  about  2250  new  references,  making  the  total 
number  in  the  present  edition  ab  ut  6000. 

The  articles  there  enumerated  as  remedies  for  particular  diseases  are  not  only  those  which, 
in  the  authors'  opinion,  are  curative,  or  even  beneficial,  but  those  also  which  have  at  any  time 
been  employed  on  the  ground  of  popular  belief  or  professional  authority.  It  is  often  of  as 
much  consequence  to  be  acquainted  with  the  worthlessness  of  certain  medicines  or  with  the 
narrow  limits  of  their  power,  as  to  know  the  we'l  attested  virtues  of  others  and  the  conditions 
under  which  they  are  displayed.  An  additional  value  posse'sed  by  such  an  Index  is,  that  it 
contains  the  elements  of  a  natural  classification  of  medicines,  founded  upon  an  analysis  of  the 
results  of  experience,  which  is  the  only  safe  guide  in  the  treatment  of  disease. 

This    evidence    of    success,    seldom    paralleled,  !  intend  to  let  the  giass  grow  uader  tbeir  feet,  but  to 


shows  clearly  how  well  the  authors  have  met  the 
existing  needs  of  the  pharmaceutical  and  medical 
professions.  Gratifying  as  it  must  be  to  them,  they 
have  embraced  the  opportunity  offered  for  a  thor- 
ough levision  of  the  whole  work,  striving  to  em- 
brace within  ir  all  that  might  have  been  omitted  in 
the  former  edition,  and  all  that  has  newly  appeared 
of  sufBcient  importance  during  the  time  of  its  col- 
laboration, and  the  short  interval  elapsed  since  the 
previous  publication.  After  hiving  gone  carefully 
through  the  volume  we  must  admit  that  the  authors 
have  labored  faithfully,  and  with  success,  in  main- 
taining the  high  character  of  their  work  as  a  com- 
pendium meeting  the  requirements  of  the  day,  to 
which  one  can  safely  turn  in  quest  of  the  latest  in- 
formation concerning  everything  worthy  of  notice  in 
connection  with  Pharmacy,  JIateria  Medica,  and 
Therapeutics. — Am.  Jour,  of  Pharmacy,  Nov.  1879. 
It  is  with  great  pleasure  that  we  announce  to  onr 
readers  the  appearance  of  a  .second  edition  of  the 
National  Dispensaiory.  The  total  exhaustion  of  the 
first  edition  in  the  short  space  of  six  months,  is  a 
sufficient  testimony  to  the  value  placed  upon  the 
work  by  the  profession.  It  appears  that  the  rapid 
sale  of  the  first  edition  must  have  induced  both  the 
editors  and  the  publisher  to  make  preparations  for 
a  new  edition  immediately  after  the  first  had  been 
Issued,  for  we  find  a  large  amount  of  new  matter 
added  and  a  good  deal  of  the  previous  text  altered 
and  improved,  which  proves  that  the  authors  do  not 


keep  the  work  up  to  the  time. — New  Remedies,  Nov. 
1879. 

This  is  a  gr^at  work  by  two  of  the  ablest  writers  on 
materia  medica  in  Amerira  The  authors  lisve  pro- 
duced a  work  which,  for  accuracy  and  comprehen.sive- 
ness,  is  unsurpassed  by  any  work  on  th-^  s  ibject.  There 
is  no  book  in  the  English  language  which  contains  so 
much  valuable  information  ou  the  various  articles  of 
the  materia  medica.  The  work  has  cost  the  authors 
ye irs  of  laborious  study,  but  they  have  succeeded  in 
producing  a  dispensatory  which  is  not  only  natimial, 
hut  will  be  a  lastinp;  memorial  of  the  learning  and 
ability  of  the  authors  who  produced  it. — Edinburyh 
Medical  Journal,  Nov.  1879. 

It  is  by  far  more  international  or  universal  than 
any  other  book  of  the  kind  in  onr  languag?,  and 
more  comprehensive  in  every  sense. — Pacific  Med. 
and  Stirg.  J  own.,  Oct.  1879. 

The  National  Dispensatory  is  beyond  dispute  the 
very  best  authority.  It  is  throughout  complete  in 
all  the  necessary  details,  clear  and  lucid  in  its  ex- 
planations, and  replete  with  references  to  the  most 
recent  writings,  where  further  particulars  can  be 
obtained,  if  desired.  Its  value  is  greatly  enhanced 
by  the  extensive  indices — a  general  in  ex  of  materia 
medica,  etc.,  and  also  an  index  of  theiajientics  It 
would  be  a  work  of  supererogation  to  say  uior^  about 
this  well-known  work.  No  practising  physician  can 
afford  to  be  without  the  National  Dispen-atory. — 
Canada  Med.  and  Surg.  Journ..  Feb    isan 


14       Henry  C.  Lea's  Son  &  Co.'s  Publications — (Pathologt/,  &c.). 


flORNIL  (F.). 

^         Frnf.  in  the  Fa 


pANVIER  [L.]. 

-*•*'         Prof  in  the  College  of  fS-ance. 


AND 

nf.  in  the  Faculty  of  Med  ,  Paris. 

MANUAL  OF  PATHOLOGICAL  HISTOLOGY.     Translated,  with 

Notes  and  Additions,  by  E.  0.  Shakespeare,  M.D.,  Pnthologist  and  Ophthalmic  Surgeon 
to  Philada.  Hospital,  Lecturer  on  Refr?ction  and  Operative  Ophthalmic  Surgery  in  Univ. 
of  Penna.,  and  by  Hekrv  C.  Simes,  M  D.,  Demonstratrr  of  Pathological  Histology  in 
the   Univ.  of  Pa.     In   one  very  handsome  octavo  volume  of  over  700  pages,  with  over 
350  illustrations.     Cloth,  $5  50;  leather,  $6  50;   half  Russia,  $7.      {Just  Ready.) 
The  work  of  Cornil  and  Ranvier  is  so  well  known  as  a  lucid  and  accurate  te.\t-book  on  its 
important  subject,  *hat  no  apology  is  needed  in  presenting  a  translation  of  it  to  the  American 
profession.     It  is  only  necessary  to  say  that  the  labors  of  Drs.   Shakespeare  and  Simes  have 
been  by  no  means  confined  to  the  task  of  rendering  the  work  into  English.     As  it  appeared  in 
Prance,  in  successive  po'"tions,  between  1868  and   1876,  a  part  of  it,  at  least,  was  soniewhit  in 
arrears  of  the  present  state  of  science,  while  the  dilfuseness  of  other  portions  rendered  conden- 
sation desirable.     The  translators  have,  therefore,  sought  to  bring  the  work  up  to  the  day, 
and,  at  the  same  time,  to  reduce  it  in  size,  aj  far  as  practicable,  without  inrairing  its  com- 
pleteneps      These  changes  will  be  found  throughout  the  volume,  the  most  extensive  being  in 
the  sections  devoted  to  Sarcoma,  Carcinoma,  Tuberculosis,  the  Bloodvessels,  the  Mnmmae,  and 
the  classification  of  tutr.ors      Corresponding  modifications  have  been  made  in  the  very  exten 
sive  and  beautiful  series  of  illustrations,  and  every  care  has  been  taken  in  the  typographical 
execution  to  render  it  one  of  the  most  attractive  volumes  which  have  issued  from  the  American 
press. 

The  translators  have  done  their  work  very  well  j  with  unusual  interest.  The  illustrations  are  by  no 
indeed,  rendering  it  into  smooth  and  excellent  Eng-  |  means  the  lea.st  valuable  part  of  the  work.  Indis- 
lish,  and   in    their   selection  of  new  material  they  j  peu.sable  as  they  are  to  any  work  of  this  nature, 


have  in  the  main  used  good  discrimination.  We 
heartily  commend  the  book  as  one  of  the  best  works 
on  the  subject. — Boston  Med.  and  Surg.  Journal, 
March  11,  ISSO. 

Their  book  is  not  a  collection  of  the  work  of  others, 
but  has  been  written  in  the  laboratory  beside  the 
microscope.  It  bears  the  niovks  >  f  personal  knowl- 
edge and  investigitiou  upon  every  puge,  controlled 
by  and  controlling  the  work  of  others.  ...  In 
short,  its  tr,\nsIatiou  has  made  it  the  best  work  in 
pathology  attainable  in  our  langnage,  one  that  every 
student,  certainly,  ought  to  have. — Archives  of  Med- 
icine, April,  1860. 

This  work,  in  the  original,  has  for  years  past 
ocenpied  a  prominent  place  in  the  library  of  French  |  by  the  authors  them.selves  in  their  own  laboratories 
pathologists,  as  we  should  naturally  be  led  to  be-  j  assisted  by  their  pupils.  As  an  aid  to  microscopists 
lieve  from  the  reputation  of  the  distinguished  au-  j  in  iheir  investigations  it  will  be  found  invaluable — 
thors.  Now  that  it  has  been  presented  to  the  Eng-  i^n  fact,  the  very  best  with  which  we  are  acquainted, 
lish   student   for   the  first  time,  it  will  be  perused  ' — Cincinnati  Med.  iV«M*,  February,  18S0. 


in  the  work  before  us  the  artist  has  sncceeiled  in 
producing  cuts  which  will  prove  unusually  valuable 
to  the  reader.  The  translation  is  well  done,  and 
gives  evidence  throughout  the  volnme  that  it  was 
made  by  a  person  thoroughly  conversant  with  the 
subject.— ivr.  r.  Med.  Gazette,  Feb.  2S,  1880, 

This  will  be  found  an  exceedingly  interesting 
and  valuable  work  by  all  who  are  engaged  in  the 
study  of.  or  take  an  interest  in,  histology — normal 
or  morbid.  The  material  which  was  utilized  in  its 
preparation  was  del ived  from  autopsies  and  opera- 
tions in  the  hospitals  of  Paris,  which  are  so  very 
rich  in  it.  Nothing  was  taken  for  granted,  but 
everything  verified   by  microscopical  investigation 


F 


G 


'EN WICK  (SAMUEL),  M.D., 

A.isistnnt  Phy.'dcian  ta  the  London  Hoxpitah 

THE  STUDENT'S  GUIDE  TO  MEDICAL  DIAGNOSIS.     From  the 

Third  Revised  and  Enlarged  English  Edition.      With  eighty-four  illustrations  on  wood. 
In  one  very  handsome  volume,  royal  12mo.,  cloth,  $2  25.     {Just  Issued.) 

RE  EN  [T.  HENRY),  M.D., 

Lecturer  on  Pn.tholngy  and  Morbid  Anatomy  at  Oharing-Cross  Hospital  Medical  School,  etc. 

PATHOLOGY  AND  MORBID  ANATOMY.    Third  American,  from 

the  Fourth  and  Enlarged  and  Revised  English  Edition.     In  one  very  handsome  octavo 
volume  of  332  pages,  with  132  illustrations;  cloth,  $2  25.      {Now   Ready.) 

ciently  numerous,  and  usually  well  made.  In  the 
p-esent  edition,  such  new  matter  has  been  added  as 
WHS  necessary  to  embrace  the  later  results  in  patho- 
logical research.  No  doubt  it  will  continue  to  enjoy 
the  favor  it  has  received  at  the  hands  of  the  profes- 
.sion. — Med   and  Surg.  Reporter,  Feb.  1,  1879. 

For  practical,  ordinary  daily  U'e,  this  is  undoubt- 
edly the  best  treatise  that  is  offered  to  students  of 
Cincinnati  Lan- 


Thia  is  unquestionably  one  of  the  best  manuals  on 
the  subject  of  patholog.v  and  morbid  anatomy  that 
can  be  plnced  in  the  sliid»ut's  hands,  and  we  are 
glad  to  see  it  kept  up  to  the  times  by  new  editions. 
Each  edition  is  enrefully  revii^ed  by  the  author,  with 
the  view  of  making  it  include  the  most  recent  ad- 
vances in  pathology,  and  of  omitting  whatever  may 
have  become  obsolete. — N.  Y.  Mf.d.  Jour.,  Feb.  1879 

The  treatiiio  of  Dr.  Green  i<  compact,  clearly  ex-  j  pathology  and  morbid  anatomy 
pressfd,  up  to  the  times,  and  popular  as  a  text-book,     cet  and  Clinic,  Feb.  S,  1S79. 
both  in  Bugland  and  America.    The  cuts  are  suffi-  I 


GLUGB'8  ATLAS  OF  PATHOLOGICAL  HISTOLOGY 
Translatei,  with  Notes  and  Additions,  by  Josbph 
Lbivy,  M.  D.  In  one  volume,  very  large  imperial 
quarto,  with  .^20  copper-plate  figures,  plain  and 
colored, cloth.     $A  00. 

PAVT'S  TREATISE  ON  THE  FUNCTION  OF  DI- 
GESTION:  its  Disorders  and  their  Treatment. 
Prom  the  second  London  edition.  In  one  band- 
some  volums,  fmall  octavo,  cloth,  1^1  00. 

LA  EOCHE  ON  YBLLOW  FEVBR. considered  in  its 
Historical,  Pathological,  Etiological,  and  Thera 
peutical  Relations.  In  two  large  and  handsome 
octavo  volumes  of  nearly  1300  pp.,  cloth.    $7  00. 


HOLLAND'S  MEDICAL  NOTES  AND  REFLEC- 
TIONS.    1  vol.  Svo.,  pp.  500,  cloth.    ilS.S  .^0. 

BARLOW'S  MANUAL  OF  THE  PRACTICE  OF 
MEDICINE.  With  Additions  by  D.  F.  Conbie 
M    D.     lvol.8vo.,pp   600,  cloth.     '«!2  .50 

TODD'SCLINICAL  LECTURES  on  CERTAIN  ACUTE 
Diseases.  In  one  neat  octavo  volume,  of  320  pp., 
cloth.    *2  so 

STOKES'  LECTURES  ON  FEVER.  Edited  by  John 
W  11,1,1  AM  MooRR,  M.  n.,  Assistant  Physician  to  the 
Cork  Street  Fever  Hospital.  In  one  neat  8vo. 
volume  cloth,  $2  00. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — {Practice  of  Medicine).  15 


f^LINT  {AUSTIN),  M.D., 

-*•  Professor  of  the  Principles  and  Practice  of  Medicine  in  Bellevue  Med.  College,  zV.  T. 

A   TREATISE    ON   THE    PRINCIPLES  AND   PRACTICE    OF 

MEDICINE  ;  designed  for  the  use  of  Students  and  Practitioners  of  Medicine.     Fourth 

edition,  revised  and  enlarged.     In  one  large  and  closely  printed  octavo  volume  of  about 

1100  pp.;  cloth,  $6  00  ;  orstrongly  bound  in  leather,  with  raised  bands,  $7  00.     iLately 

Issued. ) 

This  excellent  treatise  on  medicine  has  acquired  :  His  own  clinical  studies  and  the  latest  contribn- 

for  itself  iu  the  United  States  a  reputation  similar  to    tions  to  medical  literature  both  in  this  country  and 

that  enjoyed  in  England  by  the  admirable  lectures  ,  in  Europe,  have  received  careful  attention,  so  that 

of  Sir  Thomas  Watson.    We  have  referred  to  many    some   portions   have  been  entirely  rewritten,  and 

of  the  most  important  chapters,  and  find  the  revi-  i  about  seventypages  of  new  matter  have  been  ad- 

sion  spoken  of  in  the  preface  is  a  genuine  one,  and  I  ded.  —  Chicago  Mi-d  Jorir.,  June,  1873. 

that  the  author  has  very  fairly  brought  up  hism  alter 


to  the  level  of  the  knowledge  of  the  present  day.  The 
work  has  thisgreat  recommendation,  that  it  i.s  in  one 
volume,  and  therefore  will  not  be  so  terrifying  to  the 


Has  never  been  surpassed  as  a  text-book  for  stu- 
dents and  a  book  of  ready  reference  for  practition- 
ers.   Theforce  of  its  logic,  its  simple  and  practical 


student'  as  the  bulky  volumes  which  several  of  our  i  teachings,  have  left  it  without  a  rival  in  the  field 
-       -   -  - I  JV.  y.—lfed.  .Record,  Sept.  15,  1874. 

It  isgiven  to  veryfew  men  to  tread  in  the  steps  of 


English  text-books  of  medicine  have  developed  in  to. 
— British  and  Foreign  Med.-Chir.  Rev.,  Jan.  1875 

Itisofcourseunnecessary  tointroduce  oreulogize  !  Austin  Flint,  whose  single  volume  on  medicine, 
thi8  now  standard  treatise.  The  present  edition  j  though  hereand  there  defective,  isa  masterpiece  of 
has  been  enlarged  and  revised  to  bring  it  up  to  the  lucid  condensatioa  and  of  general  grasp  of  an  enor- 
author's  present  level  of  experience  and  reading.!  mously  wide^ubject. — Land.  Practitio7ier,Dec.'T3. 


B' 


>r  THE  SAME  AUTHOR. 

CLINICAL  MEDICINE;    a  Systematic   Treatise  on   tlie  Diagnosis 

and  Treatment  of  Diseases.     Designed  for  Students  and  Practitioners  of  Medicine.     In 

one  large  and  handsome   octavo  volume  of  795  pages;  cloth,  $4   50  ;   leather,  $5  50; 

half  Russia,  $6.      (Now  Ready.) 

It  is  here  that  the  skill  and  learniog  of  the  great  j  clearly,  and  at  the  same  time   so  concisely  as  to 

clinician  are  displayed      He  ha->  given  us  a  store-     enable  the  searcher  to  traverse  the  entire  ground 

house  of  medical  knowledge,  excellent  for  the  stu-  j  of  his  search,  and  at  the  same  time  obtain  all  that 

dent, convenient  for  the  praciitiouer,  the  lesult  of  a  I  is  essential,  without  phidding  through  au  interml- 

long  life  of  the  most  faithful  clinical  work,  collect-  j  nab'e  space. — N.  T.  Med.  Jour.,  Nov.  1879 


ed  by  an  energy  as  vigilant  and  systematic  as  un. 
tiring,  and  weighed  by  a  ju'fgment  no  less  clear 
than  his  observation  is  close. — Archives  of  Medi- 
cine, Dec.  li-79. 

The  author  of  the  above  work  has  anticipated  a 
want  long  felt  by  those  for  whom  it  was  especially 
written— the  clinical  student  during  his  pupilage, 
and  the  busy  practitioner.  He  has  given  to  the 
medical  profession  a  very  necessary  and  u.seful 
work,  complete  in  detail,  accurate  in  observation, 
brief  in  statement. — St.  Louis  Courier  of  Med., 
Oct.  1S79. 

There  is  every  reason  to  believe  that  this  book 
will  be  well  received.     The  active  practitioner  is 


The  eminent  teacher  who  has  written  the  volume 
under  consileration  has  recognized  the  needs  of 
the  American  profession,  and  the  result  is  all  that 
we  could  wish.  The  style  in  which  it  it  written  is 
peculiarly  tue  author's;  it  is  clear  and  forcible,  and 
marked  by  those  characteristies  which  have  ren- 
dered him  one  of  the  best  writers  and  teachers  this 
country  has  ever  produced.  We  have  not  space  for 
so  full  a  consideration  of  this  remarkable  work  as 
we  would  desire. — S.  Louis  Clin.  Record,  Oct.  1879. 
It  is  venturing  little  to  say  that  there  are  few  mea 
so  well  fitted  as  Dr.  Flint  to  impart  information  oa 
these  last  mentioned  subjects,  and  the  present  work 
is  a  timely  one  as  relates  both  to  the  author's  ca- 
frequently  in  need  of  some  work  that  will  enable  '  pacity  to  undertake  it  and  the  need  for  it  as  an 
him  to  obtain  information  in  the  diaguo-sis  and  accompaniment  to  the  multitude  now  issued,  in 
treatment  of  cases  with  comparatively  little  labor.  '  which  the  subject  of  treatment  is  but  little  consid- 
Dr.   Flint   has   the  faculty   of  expressing   himtelf  '  ered. — A^eio  Remedies,  Hov.  1S7 9. 


^Y  THE  SAME  AUTHOR. 

ESSAYS    ON    CONSERVATIVE    MEDICINE    AND   KINDRED 

TOPICS.     In  one  very  handsome  royal  12rao.  volume.     Cloth,  $1  38.     {Just  Issued.) 

TTZ-ATSON  (THOMAS),  M.D.,  §-c. 

LECTIJRES    ON    THE     PRINCIPLES    AND    PRACTICE    OP 

PHYSIC.  Delivered  at  King's  College,  London.  A  new  American,  from  the  Fifth  re- 
vised and  enlarged  English  edition.  Edited,  with  additions,  and  several  hundred  illustra- 
tions, by  Henry  Hartshorne,  M.D.,  Professor  of  Hygiene  in  the  University  of  Penn- 
sylvania. In  two  large  and  handsome  8vo.  vols.  Cloth,  $9  00  ;  leather,  $11  00.  {Lately 
Published.) 


H 


ARTSHORNE  {HENRY),  M.D., 

Professor  of  Hygiene  in  the  Univer.tity  of  Pennsylvania 

ESSENTIALS  OF  THE  PRINCIPLES  AND  PRACTICE  OF  MEDL 

CINE.  A  handy-book  forStudents  and  Practitioners.  Fourth  edition,  revised  and  im- 
proved. With  about  one  hundred  illustrations.  In  one  handsome  royal  12mo.  volume, 
of  about  550  pages,  cloth,  $2  6,3;  half  bound,  $2  88.     {Lately  Issued.) 


DAVIS'S  CLINICAL  LECTURES  ON  VARIOUS 
IMPORTANT  DISEASES;  being  a  collection  of  the 
Clinical  Lectures  delivered  in  the  Medicnl  Wards 
of  Marcy  Hospi  al,  Chicago.  Edited  by  Frank  H 
Davis,  M.D.  Second  edition,  enlarged.  In  one 
handsome  royal  12ino.  volume.     Cloth,  $1  75. 

THE  CYCLOPiEDIA  OF  PRACTICAL  MEDICINE: 
comprising  Treatises  on  the  Nature  and  Treatment 
of  Diseases,  Materia  Medica  and  Therapeutics,  Dis- 


eases of  Women  and  Children,  Medical  Jurispru- 
dence, etc.  etc.  By  Dunqi.ison,  Forbids,  Tweedie, 
and  CoNOLLT.  In  four  large  super  royal  octavo 
volumes,  of  .'V2.94  donble-colnraned  p ;ige>,  strongly 
and  handsomely  bound  in  leather,  $15;  cloth,  $11. 
STURGES'S  INTRODUCTION  TO  THE  STUDY  OF 
CLINICAL  MEDICINE.  Being  a  Guide  to  the  In- 
vestigation of  Disease.  In  one  handsome  12mo. 
volume,  cloth,  $1  25.    {Lately  Issued.) 


16    PIenry  C.  Lea's  Son  &  Co".'s  Publications — (Pt-acHce  of  Medicine). 


DRISrO  WK  {JOHN  SYER),  M.D.,  F.R.C.F., 

J-J  Physician  niid  Joint  Lecturer  on  Medicine,  St .  ThoTnox' .1  Hospital. 

A    TREATISE    ON    THE    PRACTICE    OF    MEDICINE.     Second 

American  edition,  revised  by  the  Author.   Edited,  with  Additions,  by  James  H.  Hutch- 
inson, M.D.,  Physiciiin   to  the   Pennn.  Hospital.     In  one   handsome  octavo  volume  of 
nearly  1200  pages.      With  illustrations.     Cloth,  $5  00;    leather,  $6  00;  half  Russia, 
$6  60.      {Nuw  Ready.) 
In   reprinting   this  work   from  the  recent  thoroughly  revised  second  English   edition,    the 
author  has  made  such  corrections  ns  seemed  ad-,  isable,  and  has   added  a  chapter  on  Insanity. 
The  Editor  has   likewise   revised   his  additions   in  the   light  of  the   latest  experience,  and  the 
work  is  presented  as  rt  fleeting  in  every  way  the  most  modern  aspect  of  medical  science,  and 
as  fully  entitled  to  miiintain  the   distinguished   position   accorded   to  it  on   both  sides  of  the 
Atlantic  as  an  authoritative  guide  for  the  student,  and    a  complete  though   concise  book  of 
reference  for  the  practitioner.     Notwithstiinding  the   author's   earnest  efi'ort   at  compression, 
the  additions  have  amounted  to  iibout  one-tenth  of  the  previous  edition  ;  but  by  the  use  of  an 
enlarged  page  these  have  been  accommodated  without  increasing  the  size  of  the  volume,  while 
a  reduction  in  the  price  renders  it  one  of  the  cheapest  works  accessible  to  the  profession. 


The  second  edition  of  tliis  excellent  work,  like  the 
first,  has  received  the  benefit  of  Dr.  Hiitehiii.«()a's 
annotHtions,  by  which  the  plia.ses  of  di.^ease  which 
are  peculiar  to  thi.s  country  are  indicated,  and  thus 
a  treatise  which  was  intended  for  •British  practi- 
tioners and  students  is  made  more  practically  ustful 
on  this  side  of  the  water.  We  see  no  reason  to 
modify  the  high  opinion  previously  expressed  with 
regard  to  Dr.  Bristowe's  work,  except  by  adding 
our  appreciation  of  the  careful  labors  of  the  author 
in  following  the  lateral  growth  of  medical  science. 
The  chapter  on  diseases  of  the  skin  and  of  the  nerv- 
ous system,  with  a  new  one  on  insanity  compiled 
from  the  best  sources  outside  of  the  KUtlor's  own 
long  experience,  and  the  valuable  portion  relating 
to  general  patholoijy,  aid  greatly  in  completing  an 
exceptionally  good  book  for  purposes  of  reference 
and  ins  ruction  — Boston  Medical  and  Surgical 
Journal,  February,  1S80. 


The  popularity  of  the  work  depends,  no  doubt, 
upon  the  clear  and  incisive  way  in  which  it  is 
written,  and  the  attention  to  details  likely  to  occur 
in  practice,  rather  than  the  discusision  ot  questions 
of  theory.  — iVtzt)  Remedies,  Jan,  1S80. 

What  we  said  of  the  first  edition,  we  can,  with 
increased  emphasis,  repeat  concerning  this:  "  Every 
page  is  chn  rHCterized  by  the  utterances  of  a  thought- 
ful man.  Wtiat  has  been  said,  has  heeu  well  said, 
and  the  book  is  a  fair  reflex  of  all  that  is  certainly 
km. ion  on  the  subjects  considered." — Ohio  Med. 
Recorder,  Jan.  7,  ISSO. 

This  is  not  only  one  of  (he  latest  and  most  com- 
prehensive works  out  on  the  general  subject  of 
Theory  and  Practice  of  Medicine,  but  it  is  unques- 
t'ouablv  one  of  the  best.— iS'o  Med.  Practiti-'ner, 
Jan.  18S0. 


piCHARDSON  [BENJ.  W.),  M.D.,  F.R.S.,  M.A.,  LL.D.,  F.S.A., 

Fellow  n/the  R'>yal  Qollege  of  Physicians,  London. 

PREVENTATIVE  MEDICINE.     In  one  octavo  volume  of  over  400 

pages.     {Ill  Press.) 

yrOODBURY  {FRAiVK),  M.D.,    '        i- 

Physician  to  the  German  Uotpital,  Philadelphia,  late  Chief  Assist,  to  Med.  Clinic,  Je.ff.  College 
Hospital,  etc. 

A    HANDBOOK   OF   THE   PRINCIPLES  AND   PRACTICE   OF 

Medicine  ;  for  the  use  of  Students  and  Practitioners.     Based  upon  Husband's  Handbook 
of  Practice.     In  one  neat  volume,  royal  12mo.      (Prejiariug.) 


H 


ABERSHON  {S.  0.)  31. D. 

Senior  Phy.H<inn  to  and  late  Lecturer  on  the  Principles  and  Practice  of  Medicine  at  Guy's 
Hospital,  etc. 

ON  THE  DISEASES  OF  THE  ABDOMEN,  COMPRISING  THOSE 

of  the  Stomach,  and  other  parts  of  the  Alimentary  Canal,  Oesophagus,  Caecum,  Intes- 
tines, ami  Peritoneum.  Second  American,  from  the  third  enlarged  and  revised  Eng- 
lish edition.  With  illustrations.  In  one  handsome  octavo  volume  of  over  600  pages. 
Cloth,  $3  50.      {Now  Ready.) 

amended  by  the  author.  Several  new  chapters  have 
been  added,  bringing  the  wo>'k  fully  up  to  the  times, 
and  making  it  a  volume  of  interest  to  the  practitioner 
in  every  field  of  inedicine  and  surgery.  Perverted 
nutrition  is  in  some  form  associated  with  all  diseases 
we  have  to  combat,  and  we  need  all  the  light  that 
can  he  obtained  on  a  subject  so  broad  and  general. 
Dr  Habershon'.s  work  is  one  that  every  practitioner 
should  read  and  study  for  himself. — X^.  Y.  Med. 
.four It.,  April,  1879. 


This  valuable  treatise  on  diseases  of  the  stomach 
and  alidon  en  has  been  out  of  print  for  several  years, 
and  is  therefore  not  so  well  known  to  the  profession 
as  it  desnrvfK  to  be.  It  will  be  found  a  cyclopjedia 
of  information,  systematically  arranged,  on  all  dis- 
eases of  the  alimenttry  tract,  from  the  mouth  to  the 
rectum  A  fiiir  proportion  of  each  chapter  is  dovit- 
ed  to  symptoms,  pathology,  and  therapeutics.  The 
present  ^dition  is  fuller  than  former  ones  in  many 
particulars,  and  has  been   thoroughly  revised  and 


F 


'OTHERGILL  {J.  MILNER),M.D.  Ediv.,  M.R.C.P.  Lend., 

Asst.  Phys.  to  the  West  T.ond   Hosp.  :  Asst.  PIn/s.  to  the  Oily  of  Lond.  Hosp..e.tc. 

THE  PRACTITIONER'S  HANDBOOK  OF  TREATMENT;  Or,  the 

Principles  of  Therapeutics.     Second  edition,  revised  and  enlarged.     In  one  very  neat 
octavo  volume  of  about  700  pages.     (In  Press.) 


-DY  THE  SAME  AUTHOR. 

THK  ANTAGONISM  OF  THERAPEUTIC  AGENTS,  AND  WHAT 

IT  TEACHES.    Being  the  Fothergillian  Prize  Essay  for  1878.    In  one  neat  volume,  royal 
I2ino.  of  166  pages;  cloth,  $1  00.     {Just  Ready.) 


Henry  C.  Lea's  Son  &  Co.'s  Publications — {Practice  of  Medicine).    17 


'OEYNOLDS  [J.  RUSSELL).  M.D., 

-*-•'         Prnf.  of  the  Principles  and  Practice  of  Medicine  in  Univ.  College,  London. 

A  SYSTEM  OF  MEDICINE   wtth  Notbs  and  Additions  by  Hii-NRY  Harts- 
HORNE,  M.D.,  late  Professor  of  Hygiene  in  the  University  of  Penna.      In  three  large  and 
handsome  octavo  volumes,  containing  3052  closely  printed  double-columneil  pages,  with 
numerous  illustrations.     Sold   only  hy  subscription.     Price  per  vol.,  in  cloth,  %^  00  ;   in 
sheep,  $fi.OO:  half  Russia,  raised  bands,  $6.50.     Per  set  in  cloth,  $15;  sheep,  $18;  half 
Russiii,  $19.50 
Volume  I.   (just  ready)  contains  General  Diseases  and  Diseases  of  the  Nervous  Svstem. 
Volume  II.    (jnst  rendy)  cont;iins  Diseases  of  Respiratory  and  Circulatoiiv  Systems. 
Volume    III.    (just  ready)    contnins    Diseases  of   the  Digestive  and  Blood  Glandular 
Systems,  op  the  Urinary  Organs,  of  the  Female  Reproductive  System,  and  of  the 
Cutaneous  System. 
Reynolds's  System  op  Medicine,  recently  completed,  has  acquired,  since  the  first  appearance 
of  the  first  volume,  the  well-deserved  reputntinn  of  being  the  work  in  which  modern   British 
medicine  is  presented  in  its  fullest  and  most  pr.TCticnl  form.     This  could  .'^earce  be  otherwi.se  in 
view  of  the  fact  that  it  is  the  result  of  the  collaboration  of  the  leading  minds  of  the  profession, 
each  subject  being  treated  by  some  gentleman  who  is  regarded  as  its  highest  authority — as  for 
instance.   Diseases  of  the  Bladder  by  Sir  Henry  Thompson,   Malpositions  of  the  Uterus  by 
Graily  Hewitt,  Insanity  by  Henry   Maudsley,   Consumption  by  J.  Hughes  Bennet,  Dis- 
eases of  the  Spine  by  CHARt^ES  Bl.\nd  Radcliffe,  Pericarditis  by  Francis  Sibson.  Alcoholism 
by  Francis  E.  Anstie,  Renal  Afiections  by  William  Roberts,   Asthma  by  Hyde   Salter, 
Cerebral  Affections  by  fc[.  Charlton  Bastian,  Gout  and  Rheumatism  by  Alfred  Baring  Gar- 
rod,  Constitutional  Syphilis  by  Jonathan   Hutchinson,  Diseases  of  the  Stomach  by  Wilson 
Fox,  Diseases  of  the  Skin  by  Balmanno  Squire,   Affections  of  the  Larynx  by  Morell  Mac- 
kenzie, Diseases  of  the  Rectum  by  Blizard  Citrling,   Diabetes  by  Lauder  Brunton,   Intes- 
tinal Diseases  by  John  Syer  Bristowe,  Catalepsy  and  Somnambulism  by  Thomas  King  Cham- 
bers, Apople.xy  by  J.  Hughlings  Jackson,   Angina  Pectoris  by  Professor  Gairdner,  Emphy- 
sema of  the  Lungs  by  Sir  William  Jenner,  etc    etc.     All  the  leading  schools  in  Great  Britain 
have  contributed  their  best  men  in  generous  rivalry,  to  build  up  this  monument  of  medical  sci- 
ence.    St.  Bartholomew's,  Guy's,  St  Thomas's,  University  College,  St   Mary's  in  London,  while 
the  Edinburgh,  Glasgow,  and  Manchester  schools  are  equally  well  represented,  the  Array  Medical 
School  at  Netley,  the  military  and  naval  services,  and  the  public  health  boards.     That  a  work 
conceived  in  such  a  spirit,  and  carried  out  under  ruch  auspices  should  prove  an  indispensable 
treasury  of  facts  and  experience,  suited  to  the  daily  wants  of  the  practitioner,  was  inevitable,  and 
the  success  which  it  has  enjoyed  in  England,  and  the  reputation  which  it   has  acquired  on  this 
side  of  the  Atlantic,  have  sealed  it  with  the  approbation  of  the  two  pre-eminently  practical  nations. 
Its  large  size  and  high  price  having  kept  it  beyond  the  reach  of  many  practitioners  in  this 
country  who  desire  to  possess  it,  a  demand  has  arisen  for  an  edition  at  a  price  which  shall  ren- 
der it  accessible  to  all.     To  meet  this  demand  the  present  edition  has  been  undertaken.     The 
five  volumes  and  five  thousand  pages  of  the  original  have,  by  the  use  of  a  smaller  type  and  double 
columns,  been  compressed  into  three  vnhunes  of  over  three  thousand  pages,  clearly  and  hand- 
somely printed,  and  offered  at  a  price  which  renders  it  one  of  the  cheapest  works  ever  presented 
to  the  American  profession. 

But  not  only  is  the  American  edition  more  convenient  and  lower  priced  than  the  English; 
it  is  also  better  and  more  complete.  Some  years  having  elapsed  since  the  appearance  of  a 
portion  of  the  work,  additions  are  required  to  bring  up  the  subjects  to  the  exi.^ting  condition 
of  science.  Some  diseases,  also,  which  are  comparatively  unimportant  in  England,  require  more 
elaborate  treatment  to  adapt  the  articles  devoted  to  them  to  the  wants  of  the  American  physi- 
cian ;  and  there  are  points  on  which  the  received  practice  in  this  country  difters  from  that 
adopted  abroad.  The  supplying  of  these  deficiencies  has  been  undertaken  by  Henry  Harts - 
horne,  M.D.,late  Professor  of  H3-giene  in  the  University  of  Pennsylvania,  who  has  endeavored 
to  render  the  work  fully  up  to  the  day,  and  as  useful  to  the  American  physician  as  it  has  proved 
to  be  to  his  English  brethren.  The  number  of  illustrations  has  also  been  largely  increased,  and 
no  effort  spared  to  render  the  typographical  execution  unexceptionable  in  every  respect. 

house  of  information,  in  regard  to  so  many  of  the 
ub.jects  with  which  he  slioald  be  familiar. — Gail- 


Really  too  much  praise  can  scarcely  be  given  to 
this  noble  book.  It  is  a  cyclopicdia  of  medicine 
written  by  some  of  the  best  men  of  Europe.  It  is 
fall  of  useful  information  snch  as  one  finds  frequent 
need  of  in  one's  daily  work  ;  for  no  one  head  can 
possibly  carry  all  the  knowledge  one  needs  in  gen- 
eral practice,  and  one  mnst  refer  sometimes  to  one's 
library.  As  a  book  of  reference  it  is  invaluable.  It 
Is  up  with  the  times.  It  is  clear  and  concentrated 
in  style,  and  its  form  is  worthy  of  its  famous  pub- 
lisher.— Louisoille  Med.  News,  Jan.  31,  1880. 

"Reynolds'  System  of  Medicine"  is  ju-tly  con- 
sidered tlie  most  popular  work  on  the  principles  and 
practice  of  medicine  in  the  English  language  The 
contributors  to  this  work  are  gentlemen  of  well- 
known  reputation  on  both  sides  of  the  Atlantic. 
Each  gentleman  has  striven  to  make  his  part  of  the 
work  as  practical  as  possible,  and  the  information 
contained  is  such  as  Is  needed  by  the  busy  pracli- 
ti.>ner.  — St.  Louin  Med.  and  iiurg.  Journ.,  Jan.  20, 
1880. 

Dr.  Hartshome  has  made  ample  additions  and 
revisions,  all  of  which  give  increased  value  to  the 
volume,  and  render  it  more  useful  to  the  Ameri- 
ean  practitioner.  There  is  no  volume  in  English 
medical  lite-ature  more  valuable,  and  every  pur- 
chaser will,  on  becoming  familiar  with  it,  congrat- 
ulate himself  on  the  possession  of  this  vaat  store- 


lard's  Med.  Journ.,  Feb.  ISSO. 

There  is  no  medical  work  which  we  have  in  times 
past  more  frequently  and  fully  consulted  wlien  per- 
plexed by  doubts  as  to  treatment,  or  by  having  un- 
usual or  apparently  inexplicable  symptoms  pre- 
sented to  us  thaa  "Reynolds'  System  of  Medicine." 
Among  its  contributors  are  gentlenieu  who  are  as 
well  known  by  reputation  upon  this  side  of  the 
Atlantic  as  in  Great  Britain,  and  whose  right  to 
speak  with  authority  upon  the  subjects  about 
which  they  have  written,  is  recognized  the  world 
over.  They  have  evidently  striven  to  make  their 
essays  as  practical  as  possible,  and  while  these  are 
sufficiently  full  lo  entitle  them  to  the  n«me  of 
monographs,  they  are  not  loaded  down  with  such 
an  amount  of  detail  as  (o  render  them  wearisome 
to  the  general  reader.  In  a  word ,  they  contain  just 
that  kind  of  information  which  the  bu.«y  practitioner 
frequently  finds  himself  in  need  of.  In  order  that 
any  deficiencies  may  be  supplied,  ihe  publishers 
have  committed  the  preparation  of  the  book  for  the 
press  to  Dr.  Henry  Hartshome,  who-e  judicious 
notesdistributed  throughout  the  volume  afford  abun- 
dant evidence  of  the  thoroughness  of  ihe  revision  to 
which  he  has  subjected  it. — Am.  Jour. Med.  Sciences, 
Jan.  1880. 


18     Henry  C.  Lea's  Son  &  Co.'s  Publications— (Prac.  of  Med. ^  &c.). 

B 


>ARTHOLO  W  (ROBERTS),  AM.,  M.D.,  LL.D. 

Prof,  of  Materia  Medica  and  General  Therapeutics  in  the  Jeff.  Med.  Coll.  of  Phila    etc 

A  PRACTICAL  TREATISE  OX  ELECTRICITY  IN   ITS    4PPLL 

CATION  TO  MEDICINE.     In  one  very  handsome  octavo  volume  of  about  450  pages, 
with  illustrations.     {Preparing.) 


piNLAYSON  [JAMES),  M.D., 

Phiisician  ar.d  Lecturer  on  Olinical  Medicine  in  the  Glasgow  We.Hern  Infirmary,  etc. 

CLINICAL  DIAGNOSIS;  A  Handbook  for  Students  and  Prac- 
titioners of  Medicine.  In  one  handsome  12mo.  volume,  of  546  pages,  with  86  illustra- 
tions.    Cloth,  $2  63.      (Jnst  Issued.) 

live  from  preface  to  the  final  page,  and  ought  to  be 
given  a  place  on  every  oftice  table,  been  use  it  contains 
inacoiideusedform  all  that  is  valuable  in  seraeiology 
and  diagnostics  to  be  found  in  bulkier  volumes,  and 
because  in  its  arrangement  and  complete  index,  it  is 
unusually  convenient  for  quick  releience  in  any 
emergency  that  may  come  upon  the  busy  practitioner. 
—  2f.  0.  Med.  Juurn.,  Jan.  1S79. 


The  book  is  an  excellent  one,  clear,  concise,  con ve- 
nieut,  practical.  It  is  replete  with  the  very  know- 
ledge the  student  needs  when  he  quits  thelecture- 
room  and  the  laboratory  for  the  ward  and  sick-room, 
and  does  not  lack  in  information  that  will  meet  the 
wants  of  experienced  and  older  mea.— Phila.  Med. 
Times,  Jan.  4,  1879. 

This  is  one  of  the  really  useful  books.    It  is  attrac- 


H 


AMILTOS  {ALLAN  McLANE),  M.D., 

Attending  Phmician  at  the  Hospital  for  Epileptics  and  Paralytics.  SlackwelPs  Island,  N.  T., 
and  at  the  Out- Patients'  Department  of  the  New  York  Hospital 

NERYOUSDISEASES;THEIR  DESCRIPTION  AND  TREATMENT. 


In  one  handsome  octavo  volume  of  512  pa 
This  is  unque.«tionably  the  best  and  most  com- 
plete text-book  of  nervous  diseases  that  has  yet  ap- 
peared, and  were  international  jealousy  in  scientific 
affairs  at  all  possible,  we  might  be  excused  for  a 
feeling  of  chagrin  that  it  should  be  of  American 
parentage.  This  work,  however,  has  been  performed 
in  New  York,  and  has  been  so  well  performed  that 
no  room  is  left  for  anything  but  commendation. 
With  great  skill,  Dr.  Hamilton  has  presented  to  ^jis 


;es,  with  53  illua. ;  cloth,  $3  50.  (Just  Issued.) 
readers  a  succinct  and  lucid  survey  of  all  that  is 
known  of  the  pathology  of  the  nervou.s  system, 
viewed  in  the  light  of  the  most  recent  researches. 
From  the  preliminary  description  of  the  metfcoda  of 
examination  and  study,  and  of  the  instruments  of 
precision  employed  in  the  investigation  of  nervous 
diseases,  up  till  the  final  collection  of  formula,  the 
book  is  eminently  practical. —.BraiTi,  London,  Oct. 
1S7S. 


M. 


fJHARCOT  {J. 

Professor  to  the  Fnattltyof  Med.  Paris,  Phys.  to  La  Salpetriire,  etc. 


LECTURES  ON  DISEASES  OF  THE  NERVOUS  SYSTEM.  Trans- 
lated from  the  Second  Edition  by  George  Sigerson,  M.D,,  M.Ch.,  Lecturer  on  Biology, 
etc.,  Cath.  Univ.  of  Ireland.    With  illustrations.    1  vol.  8vo.  of  288  pages.     Cloth,  $1  75. 


(Just  Ready.) 


CLINICAL  OBSERVATIONS  ON  FUNCTIONAL 
NERVOUS  DISORDERS  Bv  C.  Handpield Jones, 
M.D.,  Physician  to  St.  Mary's  Hospital,  &c.   Sec- 


ond American  Edition.    In  one  handsome  octavo 
volume  of  348  pages,cloth,  ijiS  25. 


MORRLS  (MALCOLM).  M.D., 

■'-''*-  Joint  Lecturer  on  Dermatology,  St.  Mary's  ffo.ipital  Med.  School. 

SKIN  DISEASES,  Including  their  Definitions,  Symptoms,  Diaa^nosis, 

Prognosis,  Morbid  Anatomy,  and  Treatment.    A  Manual  for  Students  and  Practitioners. 
In  one  12mo.  volume  of  over  300  pages.    With  illustrations.     Cloth,  $1  75.     (NowReady.) 

To^ihysicians  who  would  like  to  know  something  appliances  of  cutaneous  medicine.  He  has  produced 
about  sInn  diseases,  so  that  when  a  patient  presents  a  plain,  practical  book,  by  aid  of  which,  who  so 
himself  for  relief  they  can  make  a  correct  diagnosis  chooses  may  tr^in  his  eve  to  the  recoguiiion  of 
andprescribearationaltreatment,  we  unhesitatingly  light  but  significant  difference*.  The  descriptions 
recommend  this  little  book  of  Dr.  Morris.  The  afl'ec-  are  neither  too  vasue  nor  over-refined  ;  the  direc- 
tions of  the  skin  are  described  in  a  terse,  lucid  man-  tions  for  treatment  are  clear  and  succinct.— iowdon 
ner.  and  their  several  characteristics  so  plainly  set  Brain,  April,  1880. 
forth  that   diagno'^is  will   be   easy.     The   treatment  i      ti  .u       i       u      j,    j  ,  •         ,  . 

in  each  case  i's  such  as  the  expeHencrof  he  ^0°  '  ^.^.^..^^L'^l'^^'rin  I  '"^  his  subject  in  a  clear  and 
eminent  dermatologists  advise.-Cinciu«a«  Medi-  THZZ^^Xl\.^\  f  f  '"t°",^  to  students  his 
cat  News,  April,  ISSO.  manual  w  II  be  found  useful.-JJfs^icaZ  and  Surgi- 

'     "^     '  j  cal  Reporter,  March  27,  1880. 

This  is  emphatically  a  learner's  book  ;  for  we  can  The  author's  task  has  been  well  done  and  has  pro- 
safely  say,  so  far  as  our  judgment  goes,  that  in  the  \  daced  one  of  the  best  recent  works  upon  the  difficult 
whole  range  of  mpdical  lileralnre  of  a  like  scope,  subject  of  which  ittreats  ;  thereis  no  work  published 
there  is  no  hook  which  for  clearness  of  expression  which  gives  a  better  view  of  the  elementary  facts 
and  methodical  arrangement  is  better  adapted  to  and  principles  of  dermatology.— A'^ejo  Orleans  ilfet/i- 
promole   a    rational   conception    of  dermatology,    a    cal  and  Surgicaljournal,  k\>v\],\6&n. 

t^l^ll^T-irtllifolnL^^^^  An'n"  i     'r'"«  excellent  little  book  is   the   first  work  of  a 

1890  Ooxcrxer  of  Medicine,  April,  ^i,^i„g^,i,,,3j  p,ipi|  of  .lonathan  Hutchinson;  it  re- 

'  commends  it.^elf  above  all  by  its  clearness,  method. 

The  author  of  this  manual  has  evidently  a  full  and    an  I   precision -Prtr?*  Annates  de  Derrtiatologie  et 
intimate  acquaintance  with  the  literature  of  derma-    de  Syphiligraphie,  25  April,  ISSO. 
tology,  and  with  the  most  recent  developments  and  ' 

'OX  (  T2LBURF),  M.D.,  F.R.C.R.mid  T.  C.  FOX.  B.A.,  M.R.C.S., 

PInjsieian  to  the  Department  for  Skin  D'.-<enses,  Univfraitv  College  Hospital 

EPITOME  OF  SKIN  DISEASES.     WITH  FORMULJ^.     For  Stu- 

DENTS  AND  Practitioners.    Second  edition,  thoroughly  revised  and  greatly  enlarged.  In 
one  very  handsome  12mo.  volume  of  216  pages.     Cloth,  $1  38.     (Just  Issued.) 


F 


Henry  C.  Lea's  Son  &  Co.'s  Publications — {Dis.ofthe  Chest, d:c.).    19 


J^LINT  (AUSTIN),  M.D., 

Professor  of  the  Prinifiples  and  Practicg  of  Medicine  in  Bellevue  Hoipital  ffe.d.  College,  N.  T. 

A  MANUAL  OF  PERCUSSION  AND  AUSCULTATION;  of  the 

Phyfical  Diagnosis  of  Diseases  of  the  Lungs  and  Heart,  and  of  Thoracic  Aneurism. 
Second  edition.     In  one  handsome  roj'al  12mo.  volume:  cloth,  $1  63.      {Just  Rearly.) 

-Med.    and    Surg.    Reporter, 


Prof.  Flint  is  so  well  known  as  a  medical  teach«r  i 
and  writer  that  it  seems  superfluous  to  state  tliat 
the  subject  has  been  treated  in  a  thorough  and  sys- 
tematic manner.  In  revising  it  for  a  second  ed  tion 
the  author  has  confiued  himself  to  such  addiiions  as 
seem  likely  to  render  it  more  useful,  not  only  to 
students  engaged  in  the  practical  study  of  the  sub- 
ject, but  also  to  practitioners  as  a  hand  book  for 
ready  reference,  and  we  do  not  hesitate  in  saying 
that  it  would  prove  a  valuable  addition  to   every 


physician's  library. 
March  IS.  ISSO. 

The  little  work  before  us  has  already  become  ft 
standard  one,  and  has  become  extensively  adopted 
as  a  text-book.  There  is  certainly  none  better.  It 
contains  the  substance  of  the  losons  which  the 
author  has  for  nuny  years  given,  iu  connection  with 
practical  instruction  in  auscultation  and  percussion, 
to  private  classes,  composed  of  medical  students  and 
practitioners.  —  Cincinnati  Med.  News,  Feb.  1S80. 


or  THE  SAME   AUTHOR. 

PHTHISIS:  ITS  MORBID  ANATOMY,  ETIOLOGY,  SYMPTOM- 
ATIC EVENTS  AND  COMPLICATIONS,  FATALITY  AND  PROGNOSIS,  TREAT- 
MENT, AND  PHYSICAL  DIAGNOSIS:  in  a  series  of  Clinical  Studies.  Bj  Austin 
Flint,  M.D.,  Prof,  of  the  Principles  and  Practice  of  Medicine  in  Bellevue  Hospital  Med. 
College,  New  York.     In  one  handsome  octavo  volume  :  $3  50.     {Lately  Issued.) 


T>Y  THE  SAME  AUTHOR. 

A  PRACTICAL  TREATISE  ON  THE  DIAGNOSIS,  PATHOLOGY, 

AND  TREATMENT  OF  DISEASES  OF  THE  HEART.     Second  revised  and  enlarged 

edition.     In  one  octavo  volume  of  550  pages,  with  a  plate,  cloth,  $4. 

Dr.  Flint  chose  a  difficult  subject  for  hisrese.<rclie-.     ind  clearest  practical  treatise  on  those  subjects,  and 

and  has  shown  remarkable  powers  of  observation     should  be  in  the  hands  of  all  practitioners  and  stu- 

and  reflection,  as  well  as  greatindustry,  in  his  treat-     tents.  It  is  a  credit  to  American  medical  literature. 

ment  of  it.    His  book  mnsi  be  considered  the  fullest     —Amer.  Journ.  of  the  Mud.  Sciences,  July,  1S60. 


^1 


THE  SAME  AUTHOR. 

PRACTICAL  TREATISE    ON  THE  PHYSICAL  EXPLORA- 

TION  OF  THE  CHEST  AND  THE  DIAGNOSIS  OP  DISEASES  AFFECTING  THE 
RESPIRATORY  ORGANS.  Second  and  revised  edition.  In  one  handsome  octavo  volume 
of  595  pages,  cloth,  $4  50. 


B 


ROWN  (LENNOX),  F.R.G.S.  Ed., 

Senior  Surgeon  toihe  Central  London  Throat  and  Ear  Hi-ipifal,  etc. 

THE  THROAT   AND  ITS  DISEASES.     With  one  Inindiecl  Typical 

Illustrations  in  colors,  and  fifty  wood  engravings,  designed  and  executed  by  the  author. 
In  one  very  handsome  imperial  octavo  volume  of  361  pages  ;  cloth,  $5  00.    {Just  Ready.) 


i^ElLER  (CARL),  M.D., 

/sj  Lecturer  on  Lo.ryngoscopy  at  the  Univ    of  Penna  ,   Chief  of  the  Throat  DispejiKary  at  the 

Univ.  Hospital,  Philn  ,  etc. 

HANDBOOK  OF  DIAGNOSIS  AND  TREATMENT  OF  DISEASES  OF 

THE    THROAT   AND    NAS.AL   CAVITIES.      In   one  handsome  royal  12mo.  volume, 

of  156  pages,  with  35  illustrations;  cloth,  $1.      {Just  Ready.} 

Wemost  heartily  eommend  this  book  as  showing         A  convenient  little  handbook,  clpar,  concise,  and 

eouud  judgment  i  n  practice,  and  perfect  familiari'y     accurate  in  its  method,  and  admirably  fulfilling  its 

with   the  literature   of  tlie  specialty  it  so  ably  epi-     purpose  of  bringing  the  subject  of  which  it  treats 

tomixes. —  Philada.   itfcd.  Time*,  July  6,  1879.  within   the   comprehension    of  the  general  practi- 

I  lloner. — N.  C.  Med.  Jour.,  June,  1S79. 


WILLIAMS'S  PULMONARY  CONSUMPTION;  its 
Nature,  Varieties,  and  Treatment.  With  an  An- 
alysis of  One  Thonsind  Case.'?  to  exemplify  its 
duration.  In  one  neat  octavo  volume  of  about 
350  pages;  cloth,  $2  60. 

SLADE  ON  DIPHTHERIA;  its  Nature  and  Treat- 
ment, with  an  deoount  of  the  History  of  its  Pre- 
valenee  in  VKrious  Countries.  Second  and  i-evised 
edition.  In  one  neatroyal  12mo.  volume,  cloth, 
$1  2.5. 

WALSHE  ON  THE  DISEASES  OF  THE  HEART  AND 
GREAT  VESSELS.  Third  American  Edition.  In 
1  vol.  Svc,  420  pp.,  cloth,  *3  00. 

CHAMBERS'S  MANUAL  OF  DIET  AND  REGIMEN 
IN  HEALTH  AND  SICKNESS.  In  one  handsome 
octavo  volume.     Cloth,  $2  75. 

LA  ROCHE'oN  PNEUMONIA.  1  vol.  8vo.,  cloth, 
of  500  pages      Price,  S.'!  00. 

WILSON'S  STUDENT'S  BOOK  OF  CUTANEOUS 
MEDICINE  and  Diseases  of  the  Skin.  In  one 
very  handsome  royal  12mo   volume.     $3  60. 


FULLER  ON  DISEASES  OF  THE  LUNGS  AND  AIR- 
PASSAGES.  Their  Pathology,  Physical  Diagnosis, 
Symptoms,  and  Treatment.  From  the  second  and 
revised  English  edition.  In  one  handsome  ocatvo 
volume  of  about  500  pages  :  cloth,  ^3  50. 

SMITH  ON  CONSUMPTION  ;  ITS  EARLY  AND  RE- 
MBDIABLE  STAGES.    1  vol.  Svo.,  pp.  254.   «2  25. 

BASHAM  ON  RENAL  DISEASES:  a  Clinical  Guide 
to  their  Diagnosis  and  Treatment.  With  Illustra- 
tions.  Iu  one  12mo.  vol.  of  :H04  pages,  clo'h,  ^'2  00. 

LECTURES  ON  THE  STUDY  OF  FEVER.     By  A. 
HtJDSojf,  M.D.,  M.R.I. A.,  Physician  to  the  Meath 
Hospital      In  one  vol.  Svo.,  cloth,  4i2  50. 
!  A  TREATISE  ON  FEVER.      By  Robert  D.  Lyons, 
K.C  C.  I  a  one  octavo  volume  of  .'^62  pages,  cloth 
*2  25 

HILLIER'S  HANDBOOK  OF  SKIN   DISEASES,  for 
'      Students  and  Practitioners.     Second  Am    Ed      In 
one  roval  12mo.  vol.  of  358  pp.  With  illustrations. 
Cloth,  $2  2S. 


20    Henry  C.  Lea's  Son  &  Co.'s  Publications— (  Venereal  Diseases,  &c.). 
nUMSTEAD  {FREEMAN  J.),  M.D..LL.D., 

-*-'         Professor  of  Venereal  Diseases  at  the  Ool.  of  Phys  and  Surg..  New  York  &c 

THE  PATHOLOGY  ATs^  TREATMENT  OF  VEXEREAL   DIS- 
EASES.   Including  the  results  of  recent  investigations  upon  the  subject.    Fourth  edition 
revised    and   lnrgr°ly   rewritten  with   the   co-operation   of  R.  W.  Taylor,  M.D.,  of  New 
York,   Prof   of  Dermatology  in    the  Univ.  of  Vt.      In  one  large    and  handsome  octavo 
volume  of  8.35  pages,  with  138  illustrations.     Cloth,  $4  75  ;    leather,  $5  75  ;    half  Russia 
$6  25.      {Just  Ready.)  '      ' 

This  work,  on  its  first  appearance,  immediately  took  the  position  of  a  standard  authority  on 
Its  subject  wherever  the  language  is  spoken,  and  the  success  of  an  Italian  translation  shows 
that  It  IS  regarded  with  equal  favor  on  the  Continent  of  Europe.  In  repeated  editions  the  author 
labored  sedulously  to  render  it  more  worthy  of  its  reputation,  and  in  the  present  revision  no 
pains  h.ave  been  spared  to  perfect  it  as  far  as  possible.  Several  years  having  elapsed  since 
the  publication  of  the  th'rd  edition,  much  material  has  been  accumulated  during  the  interval 
by  the  industry  of  syphilologi.^ts,  and  new  views  have  been  enunciated.  All  this  so  far  as 
confirmed  by  observation  and  experience,  has  been  incorporated;  many  portions  of  the  volume 
been  rewritten,  the  series  of  illustrations  has  been  enlarge«l  and  improved,  and  the  whole  m.ay 
be  regarded  rather  as  a  new  work  thnn  as  a  new  edition.  It  is  confidently  pre.sented  ns  fully  on 
a  level  with  the  most  advanced  condition  of  syphilology,  and  as  a  work  to  which  the  practi- 
tioner inay  refer  with  the  certainty  of  finding  clearly  and  succinctly  set  forth  whatever  falls 
within  the  scope  of  such  a  treatise. 

We  have  to  congratulate  our  countrymen  upon  |  will  more  than  repay  him  for  the  outlay.— ^reWces 
the  trnly  valaable  addition  which  they  have  made  '  of  Medicine,  April,  1S«0. 


to  Amei-ic.in  literature.  The  careful  esiimate  of  the 
value  of  the  volume,  which  we  have  made,  instifles 
us  in  declaiing  that  this  is  the  best  treatise  on 
venereal  diseases  in  the  English  langnage,  and,  we 
might  add,  if  there  is  a  better  in  anv  other  tougiie 


This  now  clas-sical  work  on  venereal  disease  comes 
to  us  in  its  fourth  ed.tion  rewritten,  enlarged,  and 
materially  improved  in  every  way.  Dr.  Taylor,  as 
we  had  every  reason  to  expect,  has  performed  this 


we  cannot  name  it ;  there  are  certainly  no  books  in     f,^'    °  ^^  'Js  V    T       unusual  excellence.    We  feel 
which  the  student  or  the  gen«ral   practitioner  can  !    f^"^' ™  l"^s  been  wr.t  en  has  done  but  scanty  jus- 
find  snch  an  excellent  r^snmi  of  the  literature  of  J  V  !  AM       ™^"  i' :/i.^'."  ^'iK  S''«^t  treatise.--S<. 
any  topic,  and  such  practical  sug^e.stions  regarding  !  ^'"'"'  ^"""^■'- <'/  Medicine,  Feb.  18S0 
the  treatrneat  of  the  various  comiilications  of  every  j      ^^  ""•^  '^at  we  have  here  practically  a  new  book 

' —tliatthe  statement  of  the  title-page,  as  to  the  fact 
that  it  has  been  largely  rewritten,  is  a  sulBciently 
modest  announcement  for  the  important  changes  in 
the  text.  After  a  thorough  examination  of  the  pre- 
sent edition,  we  cau  assert  cunfideutly  that  the  enor- 
mous labor  we  have  described  has  been  here  most 
faithfully  and  conscientiously  performed.— Jmer. 
Journ.  Med.  Sci.,  Jan   ISSO. 

It  is  one  of  the  best  general  treatises  on  venereal 
diseases  with  which  we  are  acquainted,  and  is  espe- 
cially to  be  recommended  as  a  guide  to  the  treatment 
of  syphilis.— iondo»  Practitioner,  March,  ISSO. 


venereal  disease.  We  take  pleasure  in  repeating 
that  we  believe  this  to  be  the  best  treatise  on  vene- 
real disease  iu  the  English  language,  and  we  con- 
gratulate the  authors  upon  their  brilliant  addition 
to  American  medical  \\l»Tiitare.—Ohtiugo  Med.  Jour- 
nal and  E.vamiuer,  February,  ISSO. 

It  is,  without  exception,  the  most  valuable  single 
work  on  all  brn  nches  of  the  subiect  of  which  it  treats 
in  any  language.  The  pathology  is  sound,  the  work 
is,  at  the  same  time,  in  the  highest  degree  practical, 
and  the  hints  that  he  will  get  from  it  for  the  man- 
agement of  any  one  case,  at  all  obscure  or  obstinate, 


QULLERIER  [A.],  and         T^UMSTEAD  {FREEMAN  J.), 

-^        Surgeon  to  the  Hopital  du  Midi.  -L*       Profe.s.ior  of  Vanerea  I  Di.-.ea.tes  in  the  College  oj 

Physicians  and  Stirgeons.  N    Y 

AN  ATLAS  OF  VENEREAL  DISEASES.  Tian,slr.ted  and  Edited  by 

Freeman  J.  Bumstead.  In  one  large  imperial  4to.  volume  of32S  pages,  double-columns, 
with  26  plates,  containing  about  150  figures,  beautifully  colored,  many  of  them  the  size  of 
hfe;  strongly  bound  in  cloth.  $17  00  ;   also,  in  five  parts,  stout  wrappers,  at  $3  per  part. 
Anticipating  a  very  large  sale  for  this  work,  it  is  offered  at  the  very  low  price  ofTHREE  Dol- 
lars a  Part,  thus  placing  it  within  the  reach  of  all  who  are  interested  in  this   department  of 
practice.     Gentlemen  desiring  early  impressions  of  the  plates  would  do  well  to  order  it  without 
delay.     A  specimen  of  the  plates  and  text  sent  free  by  mail,  on  receipt  of  25  cents. 

LEE'S     LECTtJRE.S     ON     SYPHILIS    AND     SOME  i  HILL    ON    SYPHILIS  AND    LOCAL   CONTAGIOUS 
l?»}\^r  2^'^^'^*^^^  DISEASE  AFFECTING  PRIN-         DISORDERS.     In  one  handsome  octavo  volume; 
CIPALLY  THE  ORGANS  OF  GENERATION.     In        cloth,  *3  2o. 
one  handsome  octavo  volume;  cloth,  $2  25.  )  ■ 


^EST  {CHARLES),  M.D., 

Physician  to  the  Hospital  for  Sick  Ohildren,  London,  &c. 

LECTURES  ON  THE  DISEASES  OF  INFANCY  AND   CHILD- 

HOOD.  Fifth  American  from  the  sixth  revised  and  enlarged  English  edition.     In  one  large 
andhandsomeoctavovolumeof  678  pages.    Cloth,  $4  50;  leather,  $5  60.  {Lately  Issued.) 

^T  THE  SAME  AUTHOR.    (Lately  Issued.) 

ON  SOME  DISORDERS  OF  THE  NERVOUS  SYSTEM  IN  CHILD- 
HOOD; being  the  Lumleian  Lectures  delivered   at  the  Royal  College  of  Physicians  of 
London,  in  March,  1871.     In  one  volume    small  12mo.,  cloth,  $1  00. 
^  Y  THE  SA  VE  A  UTHOR. 

LECTURES  ON  THE  DISEASES  OF  WOMEN.     Third  American, 

from  the  Third  London  edition.     In  one  neat  octavo  volume  of  about  650  pages,  cloth, 
$3  75;  leather,  $4  75. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Dis.  of  Children,  &c.).    21 


UMITH{J.  LEWIS),  M.D., 

Clinical  Professor  of  Diseases  of  Qhildrpn  in  the  Bellevue  Hospital  Med.  College,  N  T. 

A  COMPLETE  PRACTICAL  TREATISE  ON  THE  DISEASES  OF 

CHILDREN.    Fourth  EditioB,  revised  and  enlarged.     In  one  hand.scme  octavo  volume 
of  about  750  pages,  with  illustrations.     Cloth,  $4  50;  leather,  $5  50;  half  Russia,  $6. 
{Not'j  Ready.) 
The  very  marked  favor  with  which  this  work  has  been  received  wherever  the  English  lan- 
guage is  spoken,  has  stimulated  the  author,  in  the  preparation  of  the  Fourth  Edition,  to  spare 
no  pains  in  the  endeavor  to  render  it  worthy  in  every  re.'^pect  of  a  continuance  of  professional 
confidence.     Many  portions  of  the  volume  have  been  rewritten,  and  much  new  matter  intro- 
duced, but  by  an  earnest  effort  at  condensation,  the  size  of  the  work  has  not  been  materially 
increased. 

In  the  period  which  has  elapsed  since  the  third  |  This  excellent  work  is  so  well  known  that  an 
edition  of  the  work,  .so  extensivp  have  been  the  ad-  •  ex'ended  notice  at  this  time  would  be  superflaons. 
vances  that  whole  chapters  required  to  be  rewiitten,  The  anihor  h,r8  taVen  advantage  of  the  demand  for 
and  hardly  a  page  could  pass  without  some  material  !  another  new  edit  on  to  revise  in  a  most  careful 
correction  or  addition.  This  labor  has  occapied  the  I  manner  the  entire  book  ;  and  the  numerous  correc- 
writer  closely,  and  he  has  performed  it  cunscien-  :  iions  and  additions  evince  a  determination  on  his 
tionsly,  so  that  the  book  may  be  considered  a  faith-  }  part  to  keep  fully  abreast  with  the  rapid  progress 
fal  portraiture  of  an  exceptionally  wide  clinical  I  that  is  being  made  in  the  knowledge  and  treatment 
experience  in  infantile  diseases,  c  rrected  by  a  care-  I  of  children's  diseases.  By  the  adoption  of  a  some- 
ful  study  of  the  recent  literature  of  the  subject. —  !  what  closer  type,  an  increase  in  size  of  only  thirty 
Med.  and  Surg.  Reporter,  April  n,  1S79.  I  pages   has   been   necessitated  by  the   new  subject 

It  is  scarcely  necessary  for  us  to  say  the  work  be-  '  matter  introduced.— Bostoji.  Med.  and  Surg.  Jour., 
fore  us  is  a  standard  work  upon  diseases  of  children,  [  '"'*^y  -"•  18'"- 

and  that  no  work  has  a  higher  standing  than  it  upon  !  Probably  no  other  work  ever  published  in  this 
those  affections.  In  consequence  of  its  thorough  re-  i  country  upon  a  medical  subject  has  reached  such  a 
tKsion,  the  work  has  been  made  of  more  value  than  [  heighth  of  populirity  as  has  this  well-known  trea- 


ever,  and  may  be  regarded  as  fully  abreast  of  the 
times.  We  cordially  commend  it  to  8tnd=*nts  and 
physicians.  There  is  no  better  work  in  the  language 
on  diseases  of  children. — Cincinnati  Med.  Aewg, 
March,  1879. 

The  author  has  evidently  determined  that  It  shall 
not  lose  ground  in  the  esteem  of  the  profession  for 
want  of  the  latest  knowledge  on  that  important 
department  of  medicine.  He  has  accordingly  in- 
corporated in  the  present  edition  the  u-eful  md 
practical  results  of  the  latest  study  and  expeiience, 
both  America  n  and  foreign,  especially  those  bearing 
on  therapeutics.  Altogether  the  book  has  been 
greatly  improved,  while  it  has  not  been  greatly 
increased  in  size.  —  New  York  Medical  Journal, 
June,  1S79. 


tise.  As  a  text  and  reference-book  it  i"  preeml- 
nently  the  authority  upon  diseases  of  children.  It 
stands  deservedly  higher  in  the  estimation  of  the 
proffssion  than  any  other  work  upon  the  same  sub- 
ject.— Nashville  Journ.  of  Med.  and  Surg.,  May, 
1879. 

The  author  of  this  work  has  acquired  an  immense 
experience  as  physician  to  three  of  the  large  char- 
ities of  New  York  iu  which  children  are  treated. 
These  asylums  afford  unsurpassed  opportunities  for 
observing  the  effects  of  different  plans  of  treatment, 
and  the  le-nlfs  a*  emb  idied  in  this  volume  may  be 
accepted  with  faith,  and  should  be  in  the  possession 
of  all  practitioners  7ioz«.  in  vi^w  of  the  approaching 
season  when  the  diseases  ofchildren  always  increase. 
—Nat.  M'd.  Review,  April,  1879. 


^WAYNE  [JOSEPH  GRIFFITHS],  M.D., 

Physician-Accoucheur  to  the  British  General  Hospital,  &e. 

OBSTETRIC  APHORISMS  FOR  THE  USE  OF  STUDENTS  COM- 
MENCING MIDWIFERY  PRACTICE     Second  American,  from  the  Fifth  and  Revised 
London  Edition    with  Additions  by  E.  R.  Hutchins,  M.D.  With  Illustrations.   In  one 
neat  12rao.  volume.     Cloth,  $]  25.     {Lately  Issued.) 
***  See  p.  3  of  this  Catalogue  for  the  terms  on  which  this  work  is  ofi'ered  as  a  premium  to 
subscribers  to  the  ' '  American  Journal  of  the  Medical  Sciences." 


CHURCHILL  Ojr  THE  PUERPERAL  FEVER  AND 
OTHER  DLSEASESPECULIAKTO  WOMEN.  1vol. 
8vo. .  pp.  t.'>n,  cloth      $2  .'50. 

DEWEES'S  TREATISE  ON  THE  DISEASES  OF  FE- 
MALES. With  illustrations.  Eleventh  Edition, 
with  the  Author's  lastimprovementsand  correc- 
tions. In  one  octavo  volume  of  536  pages,  with 
plates,  cloth.    $.3  00. 


MEIGS  ON  THE  NATURE,  SIGNS,  AND  TREAT- 
MENT OF  CHILDBED  FEVER.  1  vol.  Svo.,  pp. 
Se.'i.  cloth.    .$2  00. 

ASH  WELL'S  PRACTICAL  TREATISE  ON  THE  DIS- 
EASES PECULIAR  TO  WOMEN.  Third  American, 
from  the  Third  and  revised  London  edition.  1  vol. 
Svo. ,  pp.  528,  cloth.    $3  50. 


H 


O 


ODGE  [HUGH  L.),  M.D., 

Emeritus  Professor  of  Obstetrics ,  &e.,  in  the  University  of  Pennsylvania. 

ON  DISEASES  PECULIAR  TO  WOMEN  ;  including  Displacements 

of  the  Uterus.  With  original  illustrations.  Second  edition,  revised  and  enlc^rged.  In 
one  beautifully  printed  octavo  volume  of  531  pages,  cloth,  $4  50. 

'HURCHILL  [FLEETWOOD),  M.D.,  M.R.I.A. 
ON  THE  THEORY  AND  PRACTICE  OF  MIDWIFERY.    A  new 

American  from  the  fourth  revised  and  enlarged  London  edition.  With  notes  and  additions 
by  D.  Francis  Condie,  M.D.,  author  of  a  "Practical  Treatise  on  the  Diseases  of  Chil- 
dren," itc.  With  one  hundred  and  ninety  four  illustrations.  In  one  very  handsome  octavo 
volume  of  nearly  700  large  pages.     Cloth,  $4  00  ;  leather,  $5  00. 


MONTGOMERY'S  EXPOSITION  OF  THE  SIGNS 
AND  SYMPTOMS  OF  PREGNANCY.  With  two 
exqnisitecolored  plates,  and  numerous  wood-cnts. 
Tn  1  ^ol.Rvo..nfnearlvfinnpp..cloth,«.3  7.'). 

CONDTE'S  PRACTICAL  TREATISE  ON  THE  DIS- 
EASES OF  CHILDREN.  Sixth  edition,  revised 
and  ausmented.  In  one  large  octavo  volume  of 
80  closely- printed    pages,  cloth,  $5  25; 


RIGBY'S  SYSTEM  OF  MIDWIFERY.  With  notes 
and  Additional  Illnstrations.  Second  American 
edition.  One  volnme  octavo,  cloth  422  pages, 
*2  .W. 

SMITH'S  PRACTICAL  TREATISE  ON  THE  WAST- 
ING DISEASES  OF  INFANCY  AND  CHILDHOOD. 
Second  American,  from  the  second  revised  and 
enlarged  Eaelish  edition.     In  one  handsome  octa- 

■^^^nt.-.ma      /.Inlh       4fO    I^O 


22      Henry  C.  Lea's  Son  &  -Cc's  Publications — (Dis.  of  Women). 


rpHOMAS  {T.GAILLARD),M.D., 

I-  Profcxsor  of  Obstetrics,  Sec,  in  the  College  of  Physicians  and  Surgeons,  N.  T.,  Ac 

A  PRACTICAL  TREATISE  ON  THE  DISEASES  OF  WOMEN.  Fourth 


edition,  enlarged  and  thoroughly  revised 
800  pages,  with  191  illustrations.     Cloth 

A  work  which  h,H?  reached  a  fourth  edition,  and 
that.  too.  in  the  short  space  of  five  years,  has  achieved 
a  reputation  whicli  place?  it  almost  beyond  the  reach  ' 
of  criticism,  and  the  favorable  opinions  which  we  have 
already  expressed  of  the  former  editions  seem  to  re- 
quire that  we  should  do  little  more  than  announce 
this  new  issue.  We  cannot  refrain  from  saying  that, 
as  a  practical  work,  this  is  second  to  none  in  the  Knq^ 
lish,  or,  indeed,  in  any  other  language.  The  arransre- 
ment  of  the  contents,  the  admirably  clear  manner  in 
which  the  subject  of  the  differential  diacno.sis  of 
several  of  the  diseases  is  handled,  leave  nothinj  to  be 
desired  by  the  practitioner  who  wants  a  thoroughly 
clinical  work,  one  to  which  he  can  re<"er  in  diflficult 
cases  of  doubtful  diagnosis  with  the  certainty  of  gain- 
ing light  and  instruction.  Dr.  Thomas  is  a  man  with  a 
very  clear  head  and  decided  views,  and  there  seems  to  ' 
be  nothing  which  he  so  much  dislikes  as  hazy  notions 
of  diagnosis  and  blind  routine  and  unreasonable  thera- 
peutics. The  student  who  will  thoroughly  study  this  • 
book  and  test  its  principles  by  clinical  observation,  will  '• 
certainly  not  be  guilty  of  these  faults. — London  Lancet, 
Feb.  13,  1S75.  1 

Reluctantly  we  are  obliged  to  close  this  unsatis- 
factory no  tic  eof  so  excellent  a  work,  and  in  concl  u- 
sioa'would  remark  th»t,  as  a  teacher  of  gynecology, 
both  didactic  and  clinical,  Prof.  Thorn  as  has  certainly 
taken  the  lead  far  ahead  of  his  eonfriren,  and  as  an 
author  he  certainly  has  met  with  uniisnal  and  mer- 
ited saccBfs.— ^TO   Journ.  of  Obstetric.1,  Nov.  1874. 

This  volnme  of  Prof.  Thomas  in  its  revised  form 


In  one  large  and  handsome  octavo  volume  of 
,  $5  00;  leather,  $6  00.  (Just  Tssited.) 
is  classical  without  beingpedaaticfuU  in  the  details 
of  anatomy  and  pathology,  without  ponderous 
translation  of  pagesof  German  literature,  describes 
distinctly  the  details  and  difflcnlties  of  each  opera- 
tion, without  wearying  and  useless  minutije,  and  is 
in  all  respects  a  work  worthy  of  con  fide  nee.  justify- 
ing the  high  regard  in  which  its  distingui-shed  au- 
thor is  held  by  the  profession. — Am.  Supplement, 
Obstet.  Jonrn.,  Oct.  1874. 

ProfessorThomasfairly  took  the  Profession  of  the 
United  States  by  storrn  when  his  book  first  made  its 
appearance  early  in  1S6S.  Its  reception  was  simply 
enthusiastic,  notwithstanding  a  few  adverse  criti- 
cisms from  our  transatlantic  brethren,  the  first  large 
edition  was  rapidly  exhausted,  and  in  six  months  a 
second  one  was  issued,  and  in  two  years  athird  one 
was  announced  and  published,  and  we  are  now  pro- 
mised the  fourth.  The  popularity  of  this  work  was 
not  ephemeral,  and  its  success  was  unprecedented  in 
the  annalsof  American  medical  literature.  Six  years 
is  a  long  period  in  medical  scientific  research,  but 
Thomas's  work  on  "  Diseases  of  Women"  is  still  the 
leading  native  production  of  the  United  States.  The 
order,  the  matter,  the  absenceoftheoretical  disputa 
tiveness,  the  fairness  ofstatement,  and  the  elegance 
of  diction,  preserved  throughout  the  entire  range  of 
the  book,  indicate  that  Professor  Thomas  did  not 
overestimate  his  powers  when  he  conceived  the  idea 
and  executed  the  work  of  producing  a  new  treatise 
upon  diseases  of  women. — Prop.  Pallen,  in  Louis- 
ville Med.  Journal,  Sept.  1874. 


jyARNES  [ROBERT),  M.D..  F.R.C.P., 

■^-^  Ob.itidric  Physieian  to  St.  Thnmo.'i'K  Hotpitvl,  d-e. 

A  CLINICAL  EXPOSITION  OF  .THE  MEDICAL  AND  SUROI- 

CAL  DISEASES  OF  WOMEN.   Second  American,  from  the  Second  Enlarged  and  Revi.sed 
English  Edition.      In  one  hnndsomfl  ri(>tavo  volnnip,  of  7,S4  pages,  with  181  illustrations. 
Cloth,  $4  50  ;  leather,  $5  50  ;   half  Rus>.«ia,  $6.      iJi,st  Ready") 
The  call  for  a  new  edition  of  Dr.   Barnes's  work  on  the  Disea,=e.^  of  Females  has  encouraged 
the  author  to  make  it  even  more  worthy  of  the  favor  of  the  profe.ssion  than  before       By  a  rear- 
rangement ,Tnd  careful  pruning  space  has  been  found  for  a  new  chapter  on  the  Gynsecological 
Relations  of  the  Bladder  and  Bowel  Disorders,  without  increasing  the  size  of  the  book,  while 
many  new  illustrations  have  been  introduced  where  experience  has  shown  them  to  be  needed.    It 
is  therefore  hoped  that  the  volume  will  be  found  to  reflect  thoroughly  and  accurately  the  present 
condition  of  gynaecological  science. 

Dr  Barnes  stands  at  the  head  of  his  profession  in  the  work  is  a  vilaable  one,  and  should  be  largely 
the  old  country,  and  it  requires  but  scant  scrutiny  i  consulted  by  the  profession. — Am.  S-'pp  Obstetrical 
erf  his  book  to  show  that  it  has  been  sketched  by  a  |  Journ.  (ft.  Britain  and  Ireland,  Oct.  1S78. 
master.  It  is  plain,  practical  eommon  sense  ;  shows 
very  deep  research  without  being  pedantic;  is  emi- 
nently calculated  to  inspire  enthusiasm  without  in- 
culcating rashness;    points  out  the  dangers   to   be 


avoided  as  well  as  the  suceess  to  be  achieved  in  the 
various  operations  connected  with  this  hranch  of 
medicine;  and  will  do  much  to  smooth  the  rngged 
path  of  the  young  gynjecoljgist  and  relieve  the  per- 
plexity of  the  man  of  mature  years.  —  Canadian 
Journ.  of  Med.  Science,  Nov.  1878. 


No  other  gynajcological  work  holds  a  higher  posi- 
tion, having  become  an  authority  everywhere  in 
diseases  of  women.  The  work  has  been  brought 
fully  abreast  of  present  knowledge.  Every  practi- 
tioner of  medicine  should  have  it  upon  the  shelves 
of  his  library,  and  the  student  will  find  it  a  superior 
text-book. — Oincinnnti  Med.  New.s,  Oct.  1S7S. 


This  second  revised  edition,  of  course,  deserves  all 
the  commendation  given  to  its  predecessor,  with  the 
additional  one  that  it  appears  to  include  all  or  nearly 
We  pity  the  doctor  who,  having  any  consider- ;  all  the  additions  to  our  knowledge  of  its  subject  that 
able  practice  in  diseases  of  women,  has  no  copy  of  have  been  made  since  the  appearance  of  the  first  edi- 
"  Barnes"  for  dailv  consultation  and  instruction.  It  tion  The  American  references  are,  for  an  English 
is  at  once  a  book  of  great  learning,  research,  and  work,  especially  full  and  appreciative,  and  we  can 
individual  experience,  and  at  the  same  time  etai-  cordially  recommend  the  volume  to  American  read- 
nently  practical.  That  it  has  been  appreciated  by  ers. — Journ.  of  Nervous  and  Mental  Disease,  Oct. 
the   profession,  both   in    Great   Britain    and  in  this  '  1878. 

country,  is  shown  by  tke  second  edition  following        This  second   edition  of  Dr.  Barnes's  great  work 
80   soon  upon   the  flr8t.-,im.   Practitioner.   Nov.  ,  jo^es  to  us  containing  many  additions  and  improve- 

meats  which  bring  it  up  to  date  in  every  feature. 
Df.  Barnes's  work  is  one  of  a  practical  character,  i  The  excellences  of  the  work  are  too  well  known  to 
lairgely  illustrated  from  cases  in  his  own  experience,  require  enumeration,  and  we  hazard  the  prophecy 
but  by  no  means  confined  to  such,  as  will  be  learned  that  they  will  for  many  years  maintain  its  high  jjo- 
from  the  fact  that  he  quotes  from  no  les-s  than  628  sltion  as  a  standard  text-book  and  guide  book  for 
medical  authors  in  numerous  countries.  Coming  i  students  and  praetitiouers.  —  N.  C.  Med.  Journ., 
from  such  an  author,  it  is  not  necessary  to  say  that  ;  Oct.  1878 


QfTADWJCK  {JAMES  R.),  A.M.,  M.D. 

A  MANUAL  OF  THE   DTSE.\SES  PECULIAR  TO  WOMEN. 

neat  volume,  royal  12mo,,  with  illustrations.     {Preparing.) 


In  one 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Dis.of  Women).       23 


JPMMET  ( THOMA S  A  DDLS),  M.  D. 

-^-^  Snrffeon  to  thf.  Woman^/s  Hnspilal,  New  Torlc,  etc. 

THE  PRINCIPLES  AND  PRACTICE  OF  GYNJECOLOGY,  for  the 

use  of  Students  and  Practitioners  of  Medicine.     Second  Edition.     Thorougly  Revised, 
'  In  one  large  and  very  handsome  octavo  volume  of  875  pages,  with  133  illustrations. 

Cloth,  $5;   leather,  $6";  half  Russia,  $6  50.      {Just  Ready.) 

Preface  to  the  Second  Edition. 
The  unusually  rapid  exhaustion  of  a  large  edition  of  this  work,  while  flattering  to  the  author 
as  an  evidence  that  his  labors  have  proved  acceptable,  h.ns  in  a  great  measure  heightened  his 
sense  of  responsibility.  He  has  therefore  endeavored  to  take  full  advantage  of  the  opportunity 
afforded  to  him  for  its  revision.  Every  page  has  received  his  earnest  scrutiny;  the  criticisms 
of  his  reviewers  have  been  carefully  weighed  ;  and  while  no  marked  increase  has  been  made  in 
the  size  of  the  volume,  several  portions  have  been  rewritten,  and  much  new  matter  has  been 
added.  In  this  minute  and  thorough  revision,  the  labor  involved  has  been  much  greater  than 
is  perhaps  apparent  in  the  results,  but  it  has  been  cheerfully  expended  in  the  hope  of  rendering 
the  work  more  worthy  of  the  favor  which  has  been  accorded  to  it  by  the  profession. 

not  careles.s  reading  but  profound  study.    Its  value 


In  no  country  of  the  world  has  gynjccology  re- 
ceived moreattt*ntion  th^n  in  America.  It  is,  th^n, 
with  a  feeling  of  pleasure  that  we  welcome  a  work 
on  diseases  of  women  from  so  eminent  a  gyusecolo 
gist  as  Dr.  Emmet,  and  the  work  is  essentially  clini- 
cal, and  leaves  a  strong  impress  of  the  author's  iu- 
dividuality.  To  criticize,  with  the  care  it  mei-its, 
the  book  throughout,  would  demand  far  more  space 
than  is  at  our  command.  In  pariing,  we  can  say 
that  the  work  teems  with  original  ideas,  fresh  and 
valuable  methods  of  practice,  and  is  written  in  a 
clear  and  elegant  style,  worthy  of  the  litem  ry  repu- 
tation of  the  country  of  Longfellow  and  Oliver  Wen- 
dell Holmes.— 5ri<.  Med.  Journ.,  Feb   21,  ISSO. 

No  gyuiccologlcal  treatise  has  appeared  which 
contains  au  equal  amount  of  oiiginiil  and  useful 
matter;  n(ir  does  the  medical  and  surgical  history 
of  America  include  a  book  mom  novel  and  useful. 
The  tabular  and  statistical  information  which  it 
contains  is  mari^pllons,  both  in  quantity  and  accu- 
racy, and  cannot  be  otherwise  than  invaluable  to 
future  invest'gators.     It  is  a  work  which  demands 


as  a  contribution  lo  gynaecology  is,  perhaps, greater 
than  that  of  all  previous  literature  on  the  subject 
combined. — Chicago  Med.  Gaz.,  April  t,  ISSO 

The  wide  reputation  of  the  author  makes  its  pub- 
lication an  event  in  the  gynaecological  world  ;  and 
a  gUnce  through  its  pages  shows  tbat  it  is  a  work 
to  be  studied  with  cave.  ...  It  must  always  be  a 
work  to  be  carefully  studied  and  frequently  con- 
sulted by  those  who  practise  this  branch  of  our  pro- 
fession.— Lnnd.  Med.  Times  and  Gaz  ,  Jan.  10, 1880. 

The  character  of  the  work  is  too  well  known  to 
require  extended  notice — suffice  it  to  say  that  no 
recent  work  upon  any  subject  has  attained  such 
great  popularity  so  rapidly.  As  a  work  of  general 
reference  upon  the  subject  of  Diseases  of  Women  it 
is  invnlnable.  As  a  record  of  the  largest  clinical 
experieuce  and  observation  it  has  no  equal.  No 
physician  who  pretends  to  keep  up  with  the  ad- 
vaaces  of  this  department  of  medicine  can  afiford  to 
be  without  it. — Nashville  Journ.  of  Medicine  and 
Sttrgery,  May,  1S80. 


B 


UNCAN  {J.  MATTHEWS),  M.D.,  LL.D.,  F.R.S.E.,  etc. 

CLINICAL    LECTURES    ON    THE    DISEASES    OF    WOMEN, 

Delivered  in   Saint  Bartholomew's  Hospital.     In  one  very  neat  octavo  volume  of   173 
pages.     Cloth,  $1  50.      (Jvst  Ready.) 

The  author  is  a  remarkably  clear   lecturer,  and 

his   discussion  of  symptoms   and    treatment  is  full 

aad  sugge.'tive.     If  will  be  a  work  which  will  not 

1  to  be  read  with  benefit  by  practitioners  as  well 


They  are  in  every  way  worthy  of  their  author  ; 
indeed,  we  look  upon  them  as  among  the  most  valu- 
a;t)ie  of  his  contribu:ions  They  are  all  np^n  mat- 
ters of  great  interest  to  the  general  practitioner 


Some  of  th^m  deal  w\>h  subjects  tliat  are  not,  as  a  1  a.s  by  students.  — P^»7a.  Med.  and  Surg.  Reporter, 

rule,  adequately  hfindled  in  the  text-books ;  others  I  Feb.  7,1880. 

of  them,  while  bearing  upon  topics  that  are  usually  I       yVe    have    read   this   book   with  a  great  deal  of 


t<"eated  of  at  length  in  such  works,  yet  bear  such  a 
stamp  of  individuality  that,  if  widely  read,  as  they 
certainly  deserve  to  bo,  they  cannot  fail  to  exert  a 
wholesome  restraint  upon  tlie  undue  eagerness  with 
which  many  young  physicians  seem  bent  upon  fol- 
lowing the  wild  teachings  which  so  infest  the  gynae- 
cology of  the  present  day. — N.  X.  Med.  Journ., 
March,  ISSO. 


pleasure.  It  is  fall  of  good  things.  The  hints  on 
pathology  and  treatment  scattered  through  the  book 
are  sound,  trustworthy,  and  of  great  value.  A 
healthy  scepticism,  a  large  expeiience,  and  a  clear 
judgment  are  everywhere  manifest.  Instead  of 
bristling  with  advice  of  doubtful  value  and  nn- 
souod  character,  the  book  is  in  every  respect  a  safe 
guide. —  The  London,  Lancet,  Jan.  21,  18&0. 


JDAMSBOTHAM  [FRANCIS  H.),  M.D. 

THE  PRINCIPLES  AND  PRACTICE    OF  OBSTETRIC   MEDI- 

CINE  AND  SURQERY,  in  reference  to  the  Process  of  Parturition.  A  new  and  enlarged 
edition,  thoroughly  revised  by  the  author.  With  additions  by  W.  V.  Keating,  M.  D., 
Professor  of  Obstetrics,  &c.,  in  the  Jefferson  Medical  College,  Philadelphia.  In  one  large 
and  handsome  imperial  octavo  volume  of  650  pages,  strongly  bound  in  leather,  with  raised 
bands  ;  with  sixty-four  beautiful  plates,  and  numerous  wood-cuts  in  the  text,  containing  in 
all  nearly  200  large  and  beautiful  figures.     $7  00 


'^'INCKEL  (F.), 

'  '  Professor  and  Director  of  the  Gynacological  Clinic  in  the  University  of  Rostoch. 

A  COMPLETE  TREATISE  ON  THE  PATHOLOGY  AND  TREAT- 

MENT  op  CHILDBED,  for  Students  and  Practitioners.  Translated,  with  the  consent 
of  the  author,  from  the  Second  German  Edition,  by  James  Read  Chadwick,  M.D.  In 
one  octavo  volume.     Cloth,  $4  00.      (Lately  Issued.) 


rpANNER  {THOMAS  H.),  M.D. 

ON  THE  SIGNS  AND  DISEASES  OF  PREGNANCY.    First  American 

from  the  Second  and  Enlarged  English  Edition.     With  four  colored  plates  and  illustra- 
tions on  wood.     In  one  handsome  octavo  volume  of  about  500  pages,  cloth,  $4  25. 


24         Henry  C.  Lea's  Son  &  Co.'s  Publications — {Midwifery). 


PLAYFAIR  (  W.  S.),  M.D.,  F.R.C.F.. 
Prn/ef8or  of  Obstetric  Medicine  in  King's  College, etc.  etc. 

ATRKATTSKONTHESCTRNCP]  AND  PRACTICE  OF  MIDWIFERY. 

Third  American  edition,  revised  by  the  author.     Edited,  with  additions,  by  Robert  P. 
Harris,  M  D.     In   one  handsome  octavo  volume  of  about   700  pages,  with    nearly   2C0. 
illustrations.     Cloth,  $4;   leather,  $5;   half  Russin,  $5  60.      (Just  Ready  ) 

EXTRACT    FROM    THE    AUTHOR'S    PREFACE. 

The  second  American  edition  of  my  work  on  Midwifery  being  exhausted  before  the  corre- 
sponding English  edition,  I  cannot  better  show  my  appreciation  of  the  kind  reception  my  book 
has  received  in  the  United  States  than  by  acceding  to  the  publisher's  request  that  I  should 
myself  undertake  the  issue  of  a  third  edicion.  As  little  more  than  a  year  has  elapsed  since 
the  second  edition  was  issued,  there  are  naturally  not  many  changes  to  make,  but  I  have, 
nevertheless,  subjected  the  entire  work  to  careful  revision,  and  introduced  into  it  a  notice  of 
most  of  the  more  import.ant  recent  additions  to  obstetric  science.  To  the  operation  of  gastro- 
elytrotomy — formerly  described  along  with  the  Csesarean  section — I  have  now  devoted  a  sepa- 
rate chapter.  The  editor  of  the  Second  American  edition,  Dr.  Harris,  enriched  it  with  many 
valuable  notes,  of  which,  it  will  be  observed,  I  have  freely  availed  myself. 

The  medical  profes.-ii>n  has  now  the  opportunity  i  a  very  intfilligeat  idea  of  them,  yet  all  details  not 
of  adding  to  theT  stock  of  standard   medical  works     necessary  for  t  full  understanding  of  the  subject  are 
one  of  th*- best  volume.-*  on  midwifery  ever  pablishfd.  '  omitted. — Cinciiinati  Med.  Netcs,  Jan.  ISSO. 
The  subject  is  taken  up  with  a  ma-ster  hand.     The  [      The  rapiditv  with  which  one  edition  of  this  work 
part  devoted  to  laborin  all  it.s  various  presentations,     follows  another  is  proof  alike  of  irs  excellence  and 


the  management  and  result.?,  is  admirably  arranged 
and  the  views  entertained  will  be  found  essentially 
modern,  and  the  opinions  expressed  trustworthy 
The  work  abounds  with  plates,  illustrating  various 
obtitelrical  positions ;  they  are  admirably  wrought, 
and  afford  great  assistance  to  the  student. — N.  0. 
Med.  and  Surg.  Journ.,  March,  ISSO. 

If  inquired  of  by  a  medical  student  what  work  on 
obstetrics  we  .should  recommend  for  him,  as  pnr 
exnellen-  e.  we  would  u  doubtedly  advise  him  to 
choose  Play  fair's.  It  is  of  convenient  size,  but  what 
is  of  chief  importance,  i'.s  treatment  of  the  various 
subjects  is  concise  and  plain.  While  the  discussions 
and  descriptions  are  sufficiently  elaborate  to  render 


of  the  es'imate  that  the  profesr-iun  has  lormed  of  it. 
Ft  is  indeed  so  well  known  and  so  highly  valued 
that  nothing  need  be  said  of  it  as  a  whole.  All 
things  considered,  we  regard  tliis  treatise  as  the  very 
best  on  Midwifery  in  the  English  language.— .y.  ¥. 
Medical  Jo'irnrtl,  May,  18SU 

It  certainly  is  an  admirable  exposition  of  the 
Scienc  •  aud  Practice  of  Midwifery.  Of  course  the 
additions  made  hy  the  American  editor,  I'r.  R.  P. 
Harris,  who  never  utters  an  idle  word,  and  whose 
studious  re.-e^rches  in  tome  special  departments  of 
obstetrics  are  so  well  known  to  the  profession,  are 
of  great  value  — The  American  Praaticioner,  April, 
1880 


'DARNES  {FANCOURT),  M.D., 

-*-'  Physician  to  the  General  Lying-in  Hospital,  London. 

A  MANUAL  OF  MIDWIFERY  FOR  MIDWIYES  AND  MEDICAL 

STUDENTS.     With  60  illustrations.     In  one  neat  royal  12mo.  volume  of  200  pages; 
cloth,  $1  25.     {Now  Ready.) 


The  book  is  written  in  plain,  and  as  far  as  pos- 
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wile  or  medical  student  can  easily  comprehend  the 
directions.     It  will   undoubtedly  fill   a  want,  and 


will  be  popular  with  those  for  whom  it  has  been 
prepared.  The  exam  ning  questions  at  the  back 
will  be  found  very  useful. — Cincinnati  Med.  News, 
Aug   1P79. 


In  Monthly  Summary,  Qynbcic        28  Articles 

"                 "             Pediatric      4       " 
News 9      " 


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Original  Communications     .     .     44Articles 
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Proceedings  of  Societies   .     .    101      "  241 

In  Monthly  Summary,  Obstetric  73  ' 
and  that  it  numbers  among  it?  contributors  the  distinguished  names  of  Limbe  Atthill,  J.  H. 
Aveli.ng,  Robert  Barnes,  J.  Henry  Bennet,  Nathan  Bozeman,  Thomas  Chambers,  Fleet- 
wood Churchill,  Charles  Clay,  John  Clay,  J.  Matthews  Duncan,  Arthur  Farke,  Robert 
Gkeenhalgh,  W.  M.  Graily  Hewitt,  J.  Braxton  Hicks,  William  Leishman,  Angus  Mac- 
DONALD,  Alfred  Meadow,*!,  Alex.  Simpso.s,  J.  G.  Swayne,  Lawson  Tait,  Edward  J.  Tilt, 
E.  H.  Trbnholme,  T.  Spencer  Wells,  Arthur  Wigglesworth,  and  many  other  distin- 
guished pr.'ictitioners  Under  such  auspices  it  has  amply  fulfilled  its  object  of  presenting  to 
the  physician  all  that  is  new  and  interesting  in  the  rapid  development  of  obstetrical  and  gynae- 
cological science. 

As  a  very  large  increase  in  the  subscription  list  is  anticipated  under  this  reduction  in  price, 
gentlemen  who  propose  to  subscribe,  and  subscribers  intending  to  renew  their  subscriptions, 
are  recommended  to  lose  no  time  in  making  their  remittances,  us  the  limited  number  printed 
may  at  any  time  be  exhausted. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — {Midwifery^  Surgery).    25 


TEISHMAN  {WILLIAM),  M.D., 

Regius  Professor  of  Midwifery  in  the  University  of  Glasgow,  &c. 

A  SYSTEM  OF  MIDWIFERY,  INCLUDING  THE  DISEASES  OF 

PREGNANCY  AND  THE  PUERPERAL  STATE.  Third  American  edition,  revised  by 
the  Author,  with  additions  by  John  S.  PARRy,  M.D.,  Obstetrician  to  the  Philadelphia 
Hospital,  Ac.  In  one  large  and  very  handsome  octavo  volume,  of  733  pages,  with  over 
two  hundred  illustrations.  Cloth,  $4  50;  leather,  $5  50  ;  half  Russia,  $6.  (Just  Ready.) 
Few  works  on  this  subject  have  met  with  af  grant  I  rior  in  the  English  language. — Canada  Lancet,  Jan. 
a  demand  at  this  one  appears  to   have.     To  judge  |  ISSO. 


by  the  frequency  with  which  its  author's  views  aie; 
quoted,  and  its  statements  referred  to  in  obstetrical ' 
literature,  one  would  judge  that  there  are  few  phy- 


Tbe  book  is  greatly  improv«d,  and  as  such  will  be 
welcomed  by  those  who  are  trying  to  keep  posted  in 
the  rapid  advances  which  are  being  made  in  the 


sicians  devitiug  much  attention  to  obMetrics  who    study  of  obstetrics.— .Bos<(-»  J/ed.  a7<d  Awro  Journ 
are  without  It.     The  author  is  evidently  a   man  of    jfQy    ^1    3879 


ripe  experience  and  conservative  views,  and  in  no 
branch  of  medicine  are  these  more  valuable  than  in 
this. — Ktw  Remedies,  Jan.  ISsO. 

We  gladly  welcome  the  new  edition  of  this  excel- 
lent tfxtbookof  midwifery.  The  former  editions 
have  been  most  favorably  received  by  the  proles- 
sion  on  both  sides  of  the  Atlantic  In  the  prepara- 
tion of  the  present  edition  the  author  has  made  such 
alterations  as  the  progress  of  obstetric  il  -cieDce 
seems  to  require,  and  we  cannot  but  admire  the 
ability  with  which  the  task  has  been  performed. 
We  consider  it  an  admirable  text-book  for  stujents 


To  the  American  stadent  the  work  before  us  must 
prove  admirably  adapted,  complete  in  all  its  parts, 
essentially  modern  in  its  teachings  and  with  dem- 
on-tratious  noted  for  clearness  and  precision,  it  will 
gain  in  favor  and  be  recognized  as  a  woik  of  stand- 
ard merit  The  work  ca  unot  fail  to  be  popular,  and 
is  cordially  recommended.  — iV^.  0.  Med.  and  Surg. 
Journ.,  March,  ISSO. 

Leisbman's  is  certainly  one  of  thebest  systematic 
work^  on  midwilery.  It  is  very  complete  in  all  the 
parts  es'-ential  for  such  a  treatise      To  practitioners 


during  their  attendance  upon  lectures,  and  have  ' '^"'^  «'"'^/"'8  it  is  to  be  strongly  recommended  as  a 
great  pleasnre  in  recommending  it.  As  an  exponent  I  ^^l  ^ud  reliable  guide  to  the  modern  practice  of 
of  the  midwifery  of  the  present  day  it  has  no  supe-    ^      h  Ts89~        "  ""  Journal, 


P 


H 


ARRY  (JOHN  S.),  M.D., 

Ob,ste.trician  to  the  Philadelphia  Hospital,  Vice-Prest.  of  the  Ohstet.  S  -iciety  of  Philadelphia. 

EXTRA-UTERINE    PREGNANCY:    ITS  CLINICAL  HISTORY, 

DIAGNOSIS,    PROGNOSIS,  AND    TREATMENT.     In  one  handsome  octavo  volume. 
Cloth,  $2  60.     (Lately  Issued.) 

ODQE  {HUGH  L.),  M.D., 

Emeritus  Prof essor  of  Midwifery ,  Ac,  in  the  University  of  Pennsylvania,  <fcc. 

THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.     I'.lus- 

trated  with  large  lithographic  plates  containing  one  hundred  and  fifty-nine  figures  from 
original  photographs,  and  with  numerous  wood-cuts.  In  one  large  and  beautifully  printed 
quarto  volume  of  550  double-columned  pages,  strongly  bound  in  cloth,  $14. 


The  work  of  Dr.  Hodge  is  something  more  than 
a  simple  presentation  of  his  particular  views  in  the 
de.jartment  of  Obstetrics;  it  is  something  more 
than  an  )rdi  nary  treatise  on  midwifery;  it  is,  in  fact, 
a  cyclopadia  of  midwifery.     He  has  aimed  to  em- 


Dody  in  a  nngle  volume  the  whole  science  and  art  of 
Obstetrics.  An  elaborate  text  is  combined  with  ac- 
curate and  varied  pictorial  illustrations,  so  that  no 
fact  or  principle  Is  left  unstated  or  unexplained. 
— Am.  Med.  Time.9,  Sept.  3,  1S64. 


***  Specimens  of  the  plates  and  letter-press  will  be  forwarded  to  any  address,  free  by  mail 
on  receipt  of  six  cents  in  postage  stamps.  ' 

C^TIMSON  {LEWIS  A.),  A.E^^MJD^, 

AJ  Surgeon  to  the  Presbyterian  Hospital. 

A  MANUAL  OF  OPERATIVE  SURGERY.     In  one  very  handsome 

royal  12mo.  volume  ofabout500pages,  with  332  illustrations;  cloth,  $2  50.  (Just  Issued.) 
The  work  before  ns  is  a  well  printed,  profu.^ely    performing  them.     The  work  is  handsomelv  illns 
Illustrated  manual  of  over  lour  hundred  and  seventy  I  trated,  an.t  the  de.  criptions  are  clear  and  well'drawn 


pages.  Tne  novice,  by  a  perusal  of  the  work,  will 
gain  a  good  idea  of  the  general  domain  of  operative 
surgery,  while  the  practical  surgeon  has  presented 
to  him  within  a  very  concise  and  intelligible  form 
the  latest  and  most  approved  selections  of  operative 
procedure.  The  precision  ard  conciseness  with  which 
the  different  operations  are  described  enable  the 
author  to  compress  an  immense  amount  of  practical 
informatiou  in  a  very  small  compass. — N.  Y.  Medical 
Record,  Aug.  3,  1878. 

This  volume  is  devoted  entirely  to  operative  sur-  ..^,  »„„„„„„„  „.  .«,«,«uc«  .o  lue  practitu 

gery.  and  is  intended  to  familiarize  thestudent  with  !  -Cincinnati  Lancet  and  Clinic,  July  27   1S7S 
the  details  of  operations  and  the  different  modes  of  '  ' 


It  is  a  clever  and  useful  volume  ;  every  student 
should  possess  one.  The  preparation  of  this  work 
does  away  with  the  necessity  of  pondering  over 
larger  works  on  surgery  for  descriptions  of  opera- 
tions, as  it  presents  in  a  nnt-shell  just  what  is  wanted 
by  the  surgeon  without  an  elaborate  search  to  find 
it. — Md.  Med  Journal,  Aug.  1878. 

The  author's  conciseness  and  the  repleteness  of 

the  work  with  valuable  illustrations  entitle  it  to  be 

classed  with  the  text-books  forstudentsof  operative 

urgery,  and  as  one  of  reference  to  the  practitioner. 


SKEY'S  OPEKATIVE  SUKGERY.  In  1  vol.  8vo. 
cl.,  of  650  pages  ;  with  about  100  wood-cnts.  $3  25 

COOPER'S  LECTURES  ON  THE  PRINCIPLES  AND 
Practice  OF  Surgery.  In  1  vol.  Svo.cl'h,  750  p.  ifc2. 

GIBSON'S  INSTITUTES  AND  PRACTICE  OF  SUR- 
OERY.  Eighth  edit'n,  improved  and  altered.  With 
thirty-four  plates.  In  two  handsome  octavo  vol- 
umes, about  1000  pp.,  leather,  raised  bands.  1^6  50. 

THE  PRINCIPLES  AND  PRACTICE  OF  SURGERY. 
By  William  Pirrie.F.R.S.E.,  Profes'r  of  Surgery 
in  the  University  of  Aberdeen.    Edited  by  John 


Nbill,  M.D.,  Professor  of  Surgery  in  the  Penna 
MedicalCoUege,Surg'n  to  the  Pennsylvania  Hos- 
pital, &c.  In  one  very  handsome  octavo  vol.  of 
780  pages,  with  316  illustrations,  cloth,  $3  75.' 
MILLER'S  PRINCIPLESOF  SURGERY.  Fourth  Ame- 
rican, from  the  Third  Edinburgh  Edition.  Tn  one 
large  8vo.  vol.  of  700  pages,  with  340  illustrations 
cloth,  f  3  75.  ' 

MILLER'S  PRACTICE  OF  SURGERY.  Fourth  Ame- 
ricaD,  from  the  last  Edinburgh  Edition.  Revi.ced  bv 
the  American  editor.  In  one  large  Svo.  vol.  of  nearly 
''OO pages,  with  364  illustrations:  clotb,  $.3  76. 


26 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Surgery). 


/yROSS  {SAMUEL  D.),  M.D., 

^-^  Professor  of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia. 

SYSTEM  OF    SURGERY:   Pathological,  Diagnostic,  Therapeutic, 

and  Operative.   Illustrated  by  upwards  of  Fourteen  Hundred  Engrayings.   Fifth  edition 
carefully  revised,  and  improved.  In  two  large  and  beautifully  printed  imperial  octavo  vol- 
umes of  about  2.300  pp.,  strongly  bound  in  leather,  with  raised  bands,  $15;   half  Russia, 
raised  bands,  $16. 
The  continued  favor,  shown  by  the  exhaustion  of  successive  largeeditions  of  this  great  work, 
proves  that  it  has  successfully  supplied  a  want  felt  by  American  practitioners  and  students.     In 
the  present  revision  no  pains  have  been  spared  by  the  author  to  bring  it  in  every  respect  fully 
up  tc  the  day.     To  effect  this  a  large  part  of  the  work  has  been  rewritten,  and  the  whole  en- 
arged  bj  nearly  one-fourth,  notwith.«tanding  which  the  price  has  been  kept  at  its  former  very 
moderate  rate.     By  the  use  of  a  close,  though  very  legible  type,  an  unusually  large  amount  of 
matter  is  oondensed  in  its  pages,  the  two  volumes  containing  as  much  as  four  or  five  ordinary 
octavos-    This,  combined  with  the  most  careful  mechanical  execution,  and  its  very  durable  bind 
ing  renders,  it  one  of  the  cheapest  works  accessible  to  the  profession.    Every  subject  properly 
belonging  to  the  domain  of  surgery  is  treated  in  detail,  so  that  the  student  who  possesses  this 
work  may  be  said  to  have  in  it  a  surgical  library. 


We  have  now  brought  our  task  to  a  conclusion,  and 
have  seldom  read  a  work  with  the  practical  value  ol 
which  we  have  been  moreimpressed.  Kvery  chapter  is 
80  concisely  put  together,  that  the  busy  practitioner, 
when  in  difficulty,  can  at  once  find  theinforniation  he 
requires.  Ilis  work,  on  the  contrary,  is  cosmopolitan, 
the  surgery  of  the  world  being  fully  represented  in  it. 
The  work,  in  fact,  is  so  historically  unprejudiced,  and 
so  eminently  practical, that  it  is  almost  a  false  compli- 
ment to  say  tiiatwe  believe  it  to  be  destined  to  occupy 
a  foremost  place  as  a  work  of  reference,  while  a  system 
of  surgery  like  the  present  system  of  surgery  is  the 
practice  of  surgeons.  The  printing  and  binding  of  the 
work  is  unexceptionable;  indeed,  it  contrasts,  in  the 
latter  respect,  remarkably  with  Entrlish  medical  and 
surgical  cloth-bound  publications,  which  are  generally 
so  wretchedly  stitched  as  to  require  re-binding  before 
they  are  any  time  in  use. — Duh.  Journ.  of  Med.  Sci., 
March,  1874. 

Dr.  Gross's  Surgery,  a  great  work,  has  become  still 
greater,  botli  in  size  and  merit,  in  its  most  recent  form. 
The  difference  in  actualnumber  of  pages  is  not  more 
than  130,  but.  the  size  of  the  page  having  been  in- 
creased to  what  we  believe  is  technically  termed  "ele- 
phanl."  there  has  been  roomforconsiderableadditions, 
which,  together  with  the  alterations,  are  improve- 
ments.— Land.  Lancet,  Nov.  16, 1872. 

It  combines,  as  perfectly  as  possible,  the  qualities  of 
a  text- book  and  work  of  reference.  We  think  this  last 


edition  of  Gross's  "Surgery,"  will  confirm  his  title  of 
•'  Primus  inter  Pares."  It  is  learned,  scholar-like,  me- 
thodical, precise,  and  exhaustive.  We  scarcely  think 
any  living  man  could  write  so  complete  and  faultless  a 
treatise,  or  comprehend  more  solid,  instructive  matter 
in  the  given  number  of  pages.  The  labor  must  have 
been  immense,  and  the  work  gives  evidence  of  great 
powers  of  mind,  and  the  highest  order  of  intellectual 
discipline  and  methodical  disposition,  and  arrangement 
of  acquired  knowledge  and  personal  experience. — i\'.F. 
MeA.  Journ.,  Feb.  1873. 

As  a  whole,  we  regard  the  work  as  the  representative 
"System  of  Surgery"  in  the  English  language. — St. 
Louis  Medical  and  Surg.  Journ.,  Oct.  1872. 

The  two  magnificent  volumes  before  us  afford  a  very 
complete  view  of  the  surgical  knowledge  of  the  day. 
Some  years  ago  we  had  the  pleasure  of  presenting  the 
first  edition  of  Gross's  Surgery  to  the  profession  as  a 
work  of  unrivalled  excellence;  and  now  we  have  the 
result  of  years  of  experience,  labor. and  study,  all  con- 
densed upon  thegreat  work  before  us.  And  to  students 
or  practitionersdesirousofenrichingtheirlibrary  with 
a  treasure  of  reference,  we  can  simply  commend  the 
purchase  of  these  two  volumes  of  immense  research  — 
Qincinnati Lancetand  Observer,  Sept.  1872. 

A  complete  system  of  surgery — not  a  mere  text-hook 
of  operations,  but  a  scientific  account  of  surgical  theory 
and  practice  in  all  its  departments. — lirit.  and  For. 
Med  C/uV.iJev.,  Jan.  1873. 


B 


r  THE  SAME  AUTHOR. 

A    PRACTICAL  TREATISE   ON  THE  DISEASES,  INJURIES, 

and  Malformations  of  the  Urinary  Bladder,  the  Prostate  Gland,  and  the  Urethra.  Third 
Edition,  thoroughly  Revised  and  Condensed,  by  Samuel  W.  Gros.s,  M.D.,  Surgeon  to 
the  Philadelphia  Hospital.   In  one  handsome  octavo  volume  of  674  pages,  with  170  illus- 
trations: cloth,  $4  50.     (Just  Issued.) 
Forreferenceandgeneralinformation,  the  physician  |easeg  of  the  urinary  organs. — Atlanta  Med.  Journ., Oct. 


or  surgeon  can  find  no  work  that  meets  their  necessitief 
more  thoroughly  than  this,  a  revised  edition  of  an  ex- 
cellent treatise,  and  no  medical  library  should  be  with- 
out it.  Replete  with  handsome  illustratiins  and  good 
ideas,  it  has  the  unusual  advantage  of  being  easily 
comprehended, by  the  reasonable  and  practical  manner 
in  which  the  various  subjects  are  sy.-,teniatized  and 
arranged  We  heartily  recommend  it  to  the  profession 
as  a  valuable  addition  to  the  importan  t  literature  of  dis- 


1876. 

It  is  with  pleasure  we  now  again  take  up  this  old 
work  in  a  decidedly  new  dress.  Indeed,  it  must  be  re- 
garded as  a  new  book  in  very  many  of  its  parts.  The 
chapters  on  "Diseases  of  the  liludder,"  "  I'rostate 
Body,"  and  "Lithotomy,"  are  splendid  spe<'imens  of 
descriptive  writing;  while  the  chapter  on  "Stricture' 
is  one  of  the  most  concise  and  clear  that  we  have  ever 
read. — Neie  York  Med.  Journ., Nov. IS'^. 


TiT  THE  SAME  AUTHOR. 

A   PRACTICAL   TREATISE    ON   FOREIGN   BODIES    IN 

AIR-PASSAGES.     In  1  vol.  8vo.,  with  illustrations,  pp.  468,  cloth,  $2  75. 


THE 


T)RniTT  {ROBERT),  M.R.C.S.,  Src. 

THE  PRINCIPLES  AND  PRACTICE  OF  MODERN  SURGERY. 

A  newand  revised  American,  from  the  eighth  enlarged  and  improved  London  edition.  Illus- 
trated with  four  hundred  and  thirty-two  wood  engravings.  In  one  very  handsome  octavo 
volume,  of  nearly  700  large  and  closely  printed  pages,  cloth,  $4  00  ;  leather,  $5  00. 


All  that  the  surgical  student  or  practitionercould 
desire. — Dublin  Quarterly  Journal. 

It  is  a  most  admirable  book.  We  do  not  know 
irhen  we  have  examined  one  with  more  pleasure. — 
Boston  Med.  and  Surg.  Journal. 

In  Mr. Drnitt's  book,  though  contalningonly  some 
seven  hundred  pages,  both  the  principles  and  the 


practice  of  surgery  are  treated,  and  so  clearly  and 
perspicuously,  as  to  elucidateeveryimportinttopic. 
We  tiave  examiaed  thebook  mosttboroughly,  and 
can  lay  that  this  successis  well  merited.  His  book 
moreover,  possesses  the  inestimable  advantages  of 
having  the  subjects  perfectly  well  arranged  and 
clafsifled  and  of  being  written  in  a  style  at  once 
clearand  succinct. — Am.  Journal  of  Med.  Sciences. 


Henry  C.  Lea's  Son  &  Co.'s  Publications— (Surgery). 


27 


A  SHHURST  {JOHN,  Jr.),  M.D.,  .,  ,  p,-,  w  ;  ..„ 

-^  Prnf  of  ainicai  Surgery,  Univ.  of  Pa.,  Surgeon  to  the  Episcopal  Hospital,  Philadelphia. 

THE    PRINCIPLES  AND  PRACTICE  OF  SURGERY.     Second 

edition  enlarged  and  revised.  In  one  very  large  and  handsome  octavo  volume  of  over 
1000  pages,  with  642  illustrations.  Cloth,  $6;  leather,  $7;  half  Russia,  $7.50,  (Just 
Ready.) 


CooecieDtiousness  and  fhoronghness  are  two  very 
marked  trails  of  character  iu  the  author  of  this 
book.  Out  of  these  traits  largely  has  grown  the 
success  of  his  mental  fruit  In  the  past,  and  the  pre- 
sent offer  seems  in  no  wise  an  exception  to  what  has 
gone  before.  The  general  arrangement  of  the  vol- 
ume is  the  same  as  in  the  first  edition,  but  every  part 
has  been  carefully  revised,  and  much  new  matter 
added.— P/uZa.  Med.  Times,  Feb.  1,  1S79. 

We  have  previously  spoken  of  Dr.  Ashhurst's 
work  In  terms  of  praise.  We  wish  to  reiterate  those 
terms  here,  and  to  add  that  no  more  satisfactory 
representation  of  modern  surgery  has  yet  fallen 
from  the  prp.ss.  In  point  of  judicial  fairness,  of 
power  of  condensation,  of  accuracy  and  conciseness 
of  expression  and  thoroughly  good  English,  Prof. 
Ashhurst  has  no  superior  among  I  he  surgical  writers 
in  America.— ylwi.  Practitioner,  Jan.  1S79. 

The  attempt  to  embrace  iu  a  volume  of  1000  pages 
the  whole  field  of  surgery,  general  and  special, 
would  be  a  hopeless  task  unless  through  the  mos^t 
tireless  industry  in  collating  and  arranging,  and 
the  wisest  judgment  in  condensing  and  excluding. 
These  facilities  have  been  abundantly  employed  by 
the  author,  and  he  has  given  us  a  most  excellent 
treatise,  brought  op  by  the  revision  for  the  second 
edition  to  the  latest  date.  Of  course  this  book  is  not 
designed  for  specialists,  but  as  a  course  of  general 
surgical  knowledge  and  for  general  practitioners, 
and  as  a  text-book  for  students  it  is  not  surpassed 
by  any  that  has  yet  appeared,  whether  of  home  or 
foreign  authorship.— .iV.  Oarolina  Med.  Journal, 
Jan.  1S79. 


Ashhurst's  Surgery  is  too  well  known  in  this 
country  to  require  special  commendation  from  us. 
This,  its  second  edition,  enlarged  and  thoroughly 
revised,  brings  it  nearer  our  idea  of  a  model  text- 
book than  any  recently  published  treatise.  Though 
numerous  additions  have  been  made,  the  size  of  the 
work  is  not  materially  increased  The  main  trouble 
of  text  books  of  modern  times  is  that  they  are  too 
cumliersome.  The  student  needs  a  book  which  will 
furnish  him  the  most  information  in  the  shortest 
time.  In  every  respect  this  work  of  Ashhurst  is 
the  model  text-book- full,  comprehensive  and  com- 
pact.—A't/.s/ivii/f,  Jour,  of  Med.  and  Surg.,  Jan.  '79. 

The  favorable  reception  of  the  first  edition  is  a 
guarantee  of  the  popularity  of  this  tditiou,  which  is 
fresh  from  the  editor's  hands  with  many  enlarge- 
ments and  improvements.  The  author  of  this  work 
is  deservedly  popular  as  an  editor  and  writer,  and 
his  contributions  to  the  literature  of  surgery  have 
gained  for  him  wide  reputation.  The  volume  now 
offered  the  profession  will  add  new  laurels  to  those 
already  won  by  previous  contributions,  We  can 
only  add  that  the  work  is  well  airaug<  d,  filled  with 
practical  matter,  and  contains  in  brief  and  clear 
langua'.;e  all  that  is  necessary  t^)  be  learned  by  the 
student  of  surgery  whilst  in  attendance  upon  lec- 
tures, or  the  general  practitioner  in  his  daily  routine 
practice. — Md.  Med.  Jourrtal,  Jan,  1S79. 

The  fact  that  this  work  has  reached  a  second  edi- 
tion so  very  soon  after  the  publication  of  the  first 
one,  speaks  more  highly  of  its  raerit.i  than  anything 
we  might  say  in  the  way  of  commendation.  It 
seems  to  liave  immediately  gained  the  favor  of  stu- 
dents and  physicians. — Oincin.  Med.  News,  Jaa.  '79. 


B 


RYANT  [THOMAS),  F.R.C.S., 

Surgeon  to  Ouy's  Hospital. 

THE  PRACTICE  OF  SURGERY.     Second  American,  from  the  Sec- 
ond nnd  Revised  English  Edition.     With  Six  Hundred  and  Seventy  two  Engravings  on 
Wood      In  one  large  and  very  handsome  imperial  octavo  volume  of  over  lOUO  large  and 
closely  printed  pages.     Cloth,  $6  ;   leather,  $7.     {Just  Ready.) 
This  work  has  enjoyed  the  advantage  of  two  thorough  revisions  at  the  hand  of  the  author  since 
the  -iDpearanee  of  the  first  American  edition,  resulting  in  a  very  notable  enlargement  of  size  and 
imm-ovement  of  matter.     In  England  this  has  led  to  the  division  of  the  work  into  two  volumes, 
which  are  here  comprised  in  one,  the  size  being  increased  to  a  large  imperial  octavo,  printed  on 
a  condensed  but  clear  type.     The  series  of  illustrations  has  undergone  a  like  revision,  and  will 
be  found  correspondingly  improved.  r.._      a^i      *•      i-  *i,   *  ti,         iu       i. 

The  rairked  success  of  the  work  on  both  sides  of  the  Atlantic  shows  that  the  author  has  suc- 
ceeded in  the  effort  to  give  to  student  and  practitioner  a  sou  ,d  and  trustworthy  guide  in  the 
cractice  of  Surgery;  while  the  simultaneous  appearance  ot  the  present  edition  in  England  and 
in  this  country  affords  to  the  American  reader  the  benefit  ol  the  most  recent  advances  made 
abroad  in  surgical  science. 

There  are  so  many  textbooks  of  surgery,  so  many,  Another  edition  of  this  manual  having  been  called 
written  bv  .skilled  and  di.st.ngui8bed  hands,  that  to  ob  1  for,  the  author  has  availed  hnn,elt  of  the  opportunity 
tain  the  bouor  of  a  third  edition  in  England  is  no  li;ibt  i  to  maice  no  few  alteialions  in  the  substance  as  well 
..raise  Mr  Bryant  merits  this,  by  clearne.ss  of  style.  |  as  in  the  arrangement  of  the  work,  and,  with  a  view 
andyood  judgment  in  selecting  the  operations  he  re- j  to  its  improvenient.^^has  recast^lhe  materials  and  re 
commends,  iu  his  new  eilitions  he  goes  carefully  over       -    -^   •^~       --    '-  - 


the  old  grounds,  in  light  of  later  research.  On  these 
and  many  allied  points,  Mr.  Bryant  is  a  calm  and  un- 
purti.san  observer,  and  his  book  throughout  has  the 
great  merit  of  maintaining  the  true  scientific,  judicial 
tone  of  mind.— jWerf.  and  Surg.  Reporter,  March  22, 
1S79. 

The  work  before  us  is  the  American  reprint  of  the 
last  London  edition,  and  has  the  advantage  over  the 
latter  in  beinfj  of  more  convenient  size,  and  in  being 
compressed  into  one  volume.  The  author  has  rewrit- 
ten the  greater  part  of  the  work,  and  has  succeeded, 
in  the  amount  of  new  matter  added,  in  making  it  mark- 
edly distinctive  from  previous  ediiions.  A  few  extra 
pai-ofi  have  been  added,  and  also  a  few  new  illustrations 
introduced.  The  publishers  have  presented  the  work 
in  a  creditable  style.  As  a  concise  and  practical  manual 
of  British  surgery  it  is  perhaps  without  an  equal,  and 
will  doubtless  always  be  a  favorite  text-book  with  the 
student  and  practitioner.— iV^.  l\  Med.  Record,  March 
22, 18T-9. 


vised  the  whole.  We  ourselves  are  of  the  opinion 
that  there  is  no  better  work  on  surgery  extant. — 
ClfCinnaXi  Med.  News,  March,  1879. 

Bryant's  Surgery  has  been  favorably  received  from 
the  first,  and  evidently  grows  in  the  esteem  of  the 
profession  w.th  each  succeeding  edition.  In  glanc- 
ing over  the  volume  before  as  we  find  proof  in  almost 
every  chapter  of  the  thorough  revision  which  the 
worli  has  undergone,  many  parts  having  been  cut 
out  and  replaced  by  matter  entirely  fresh. — N.  Y. 
Med.  Journ.,  April,  1879. 

Welcome  as  the  new  edition  is,  and  as  much  as  it 
is  entitled  to  commendation,  yet  its  appearance  at 
this  time  is,  in  a  cer'.ain  sense,  a  matter  of  regret,  as 
it  will  be  in  competition  with  another  work,  lately 
issued  from  the  same  press.  But,  tlie  difficult  task 
of  forming  a  judgment  ae  to  the  relative  merits  of 
Bryant  and  Ashhurst  we  will  not  attempt,  but  pre- 
dict that,  considering  the  high  excelleuoe  of  both, 
many  others  will  likewise  be  forced  to  hesitate  long 
in  making  choice  between  them.  —  Ginoinnati  Lan- 
cet and  Olinie,  March  22,  1879. 


28 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Surgery). 


j^RICHSEN  {JOHN  E.), 

Professor  of  Surgery  in  University  College,  London,  etc. 

THE  SCIENCE  AND  ART  OF  SURGERY;  being  a  Treatise  on  Sur- 

gical  Injuries,  Diseases,  and  Operations.  Carefully  revised  by  the  author  from  the 
Seventh  and  enlarged  English  Edition.  Illustrated  by  eight  hundred  and  si.xty  two  en- 
gravings on  wood.  In  two  large  and  beautiful  octavo  volumes  of  nearly  2000  pages  : 
cloth,  $8  50  ;  leather,  $10  50;  half  Russia,  $11  60.     (Now  Ready.) 

In  revising  this  standard  work  the  authorhas  spared  no  pains  to  render  it  worthy  of  a  continu- 
ance of  the  very  marked  favor  which  it  has  so  long  enjoyed,  by  bringing  it  thoroughly  on  a 
level  with  the  advance  in  the  science  and  art  of  surgery  made  since  the  appearance  of  the 
last  edition.  To  accomplish  this  has  required  the  addition  of  about  two  hundred  pages  of  text, 
while  the  illustrations  have  undergone  a  marked  improvement.  A  hundred  and  fifty  additional 
wood-cuts  have  been  inserted,  while  about  fifty  other  new  ones  have  been  substituted  for  figures 
which  were  not  deemed  satisfactory.  In  its  enlarged  and  improved  form  it  is  therefore  pre- 
sented with  the  confident  anticipation  that  it  will  maintain  its  position  in  the  front  r.nnk  of 
text-books  for  the  student,  and  of  works  of  reference  for  the  practitioner,  while  its  exceedingly 
moderate  price  places  it  within  the  reach  of  all. 


The  seveQth  edition  is  before  the  world  as  the  last 
word  ot  surgical  science.  There  may  be  monographs 
which  excel  it  upon  certain  points,  but  as  a  con- 
spectus upon  surgical  principles  and  practice  it  is 
unrivalled.  It  will  well  reward  practitioners  to 
read  it,  for  it  Las  been  a  peculiar  province  of  Mr. 
Erichsen  to  demonstrate  the  absolute  interdepend- 
ence of  medical  and  surgical  science  We  need 
scarcely  add,  in  conclusion,  that  we  heartily  com- 
mend the  work  to  students  that  they  may  be 
grounded  in  a  sound  faith,  and  to  practitioners  as 
an  invaluable  guide  at  the  bed.-iide. — Am  Practi- 
tioner, April,  1S78. 

It  is  no  ille  compliment  to  say  that  thisis  the  best 
edition  Mr.  Erichsen  has  ever  produced  of  his  well- 
known  book.  Besides  inheriting  the  virtues  of  iis 
predecessors,  it  possesses  excellences  quite  its  own. 
Having  stated  that  Mr.  Erichsen  his  incorporated 
into  this  edition  every  recent  improvement  in  the 
science  and  art  of  surg^^ry.it  would  be  a  supereroga- 
tion to  give  a  detailed  ciilicism.  In  short,  we  un- 
hesitatingly aver  that  we  know  of  no  other  single 
work  where  the  student  and  practitioner  can  gain  at 
once  so  clear  an  insight  into  the  principles  of  surgery, 
and  so  complete  a  knowledge  of  the  exigencies  of 
surgical  practice.— iondon  irincei,  Feb.  14,  187S 

For  the  past  twenty  years  Erichson's  Surgery  has 
maintained  its  place  as  the  leading  text-book,  not  only 
in  this  country,  but  in  (3reat  Britain.  That  it  is  able 
to  hold  its  ground,  is  abundantly  proven  by  the  tho- 
roughness with  which  the  present  edition  has  been 
revised,  and  by  the  large  amount  of  valuable  mate- 
rial that  has  been  added.  Aside  from  this,  cne  hun- 
dred and  fifty  new  illustrations  have  been  inserted, 
including  quite  a  number  of  microscopical  appear- 
ances of  pathiiljgical  processes.  So  marked  is  this 
change  for  the  better,  that  the  work  almost  appears 
as  an  entirely  new  one. —ilfefi.  Record,  Feb.  23,1878. 


Of  the  many  treatises  on  Sursery  which  it  has  been 
our  task  to  study,  or  our  pleasure  to  read,  there  is  none 
which  in  all  points  has  satisfied  us  so  well  as  the  classic 
treatise  of  Erichsen.  His  polished,  clear  style,  his  free- 
dom from  prejudice  and  hobbies,  hisunsurpassed  grasp 
of  his  subject,  aud  vast  clinical  experience,  qualify  him 
admirably  to  write  a  model  text-book.  When  we  wish, 
at  the  least  cost  of  time,  to  learn  the  most  of  a  topic  in 
surgery,  we  turn,  by  preference,  to  bis  work.  It  is  a 
pleasure,  therefore,  to  see  that  the  appreciation  of  it  is 
general,  and  has  led  to  the  appearance  of  another  edi- 
tion.— Med.  and  Surg.  lieiiorli-r,  Feb.  a,  1S78. 

Notwithstanding  the  increase  in  size,  we  observe  that 
much  old  matter  has  been  omitted.  The  entire  work 
has  been  thoroughly  written  up,  and  not  merely  amend- 
ed by  a  few  extra  chapters  A  great  improvement  has 
been  made  in  the  illustrations.  One  hundred  and  fifty 
new  ones  have  been  added,  and  many  of  the  old  ones 
have  been  redrawn.  The  author  highly  appreciates  the 
favor  with  which  his  work  has  been  received  by  Ameri- 
can surgeons,  and  has  endeavored  to  render  his  latest 
edition  more  than  ever  worthy  of  their  approval.  That 
he  has  succeeded  admirably,  must,  we  think,  be  the 
general  opinion.  We  heartily  recommend  the  book  to 
both  student  and  practitioner. — N.  Y.  Med.  Journal, 
Feb.  1878. 

Erichsen  has  stood  so  prominently  forward  for 
years  as  a  writer  on  Surgery,  that  his  reputation  is 
world  wide,  and  his  name  is  as  familiar  to  the  med- 
ical student  as  to  the  accomplished  and  experienced 
surgeon.  The  work  is  not  a  reprint  of  former  edi 
tions,  but  has  in  many  places  been  entirely  rewrit- 
ten. Recent  improvements  in  surgery  have  not  es. 
caped  his  notice,  various  new  operations  have  been 
thoroughly  analyzed,  and  their  merits  thoroughly 
discussed.  One  hundred  and  fifty  new  wood-cuts 
add  to  the  value  of  this  work. — N.  O.  Med.  and  Surg. 
Jotirnal,  March,  1S7S. 


H 


OLMES  {TIMOTHY),  M.D., 

Snrgnonto  St.  George's  Hospital,  London. 

SURGERY,  ITS  PRINCIPLES  AND  PRACTICE.     In  one  hand- 

some  octavo  volume  of  nearly  1000  pages,  with  411  illustrations.  Cloth,  $6;  leather,  $7  : 
half  Russia,  $7  50.     (^Jv.st  Issued.) 

N.  y.  Med.  Record,  April 


This  is  a  work  which  has  been  lookedforonboth  i  its  force  and  distinctness 
Bides  ofthe  Atlantic  with  much  interest.  Mr.  Holmes  |  14,  1876. 
Is  a  surgeon  ot  large  aud  varied  experience,  and  one 
of  the  best  known,  and  perhaps  the  most  biilliant 
writer  upon  surgical  subjects  in  England.  It  is  a 
book  for  students — and  an  admirable  one — and  for 
the  busy  general  practitioner  It  will  give  a  student 
all  the  knowledge  needed  to  pass  a  rigid  examina- 
tion. The  book  fairly  J  Uhti ties  the  high  expectations 
that  were  formed  of  it.  Its  style  is  clear  and  forcible, 
even  brilliant  at  times,  and  the  conciseness  needed 
to  b  ring  it  within  its  properlimits  has  not  impaired 


It  will  be  found  a  most  excellent  epitome  of  sur- 
gery by  the  general  practitioner  who  has  not  the 
time  togiveattention  to  more  minute  and  extended 
works  and  to  the  medical  student.  In  fact,  we  know 
of  uo  one  we  can  more  cordially  recommend.  The 
author  has  succeeded  well  in  giving  a  plain  and 
practical  account  of  each  .surgical  injury  and  dis- 
ease, and  of  the  treatment  which  is  most  com- 
monly advisable.  It  will  no  doubt  become  a  popu- 
lar work  in  the  profession,  and  especially  as  a  text- 
book.— Cincinnati  Med.  News,  April,  1876. 


ASHTON  ONTHE  DISEASES,  INJURIES,  and  MAL-  I  SARGENT  ON  BANDAGING  AND  OTHER  OPERA- 


FORMATIONS  Op  THE  RECTUM  AND  ANUS: 
with  remarks  on  Habitual  Constipation.  Second 
American,  from  the  fourth  and  enlarged  London 
Edition.  With  illustrations.  In  one  8vo.  vol.  of 
287  pageB,  cloth, $3  26. 


TIONS  OF  MINOR  SURGERY.  New  edition,  with 
an  additional  chapter  on  Military  Surgery.  One 
12mo.  vol.  ol3S3pag9s  withlSl  wood-cuts.  Cloth, 
$175. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — {Ophthalmology). 


29 


fJAMILTON  {FRANK  H.),  M.D., 

•*-*■  Professorof  Fractures  and  Dislocations,  Ac,  in  Bellevue  Hasp.  Med.  College,  New  Fork. 

A  PRACTICAL  TREATISE  ON   FRACTURES  AND  DISLOCA- 

TIONS.  Fifth  edition,  revised  and  improved.  In  one  large  and  handsome  octavo  volume 
of  nearly  800  pages,  with  344  illustrations.  Cloth,  $6  75  ;  leather,  $6  75.  (Lately  Issned.) 


There  is  no  better  work  on  the  subject  in  existence 
than  that  of  Dr.  Hiimilton.  It  should  be  in  the  posses- 
sion of  erery  treneral  practitioner  and  surgeon.  — T/if 
Am.  Jnurn.  of  Obstetrics,  Feb.  1S76. 

The.value  of  a  work  like  this  to  the  practical  physi- 
cian andsurgeon  canhardly  beover-estimateil.and  the 
necessity  of  having  such  a  book  revised  to  the  latest 
dates,notmerelyonaccountof  the  practical  importance 


of  its  teachings,  but  also  by  reason  of  the  meilico-le^al 
beariugsof  the  case.*  of  which  it  treats,  and  which  have 
recently  been  the  subject  of  useful  papers  by  l)r.  Hamil- 
ton and  others,  is  sufficiently  obvious  to  every  one.  The 
present  volume  seems  to  amply  fill  all  the  requisites. 
We  can  safely  recommend  it  as  the  best  of  its  kind  in 
the  English  language,  and  not  excelled  in  an.v  other  — 
Journ.of  ISltroous  and  Mental  Disease.  3 a.n  1876. 


KTETTLESRIP  {EDWARD),  F.R.C.S., 

-^  *  Opkth'ilmic  Surg,  and  Lecf.  on  Ophth.  Surg,  at  St.  Thomas'  Hospital,  London. 

MANUAL    OF    OPHTHALMIC    MEDICINE.     In  one  royal  12ino. 

volume  of  over  350  pages,  with  89  illustrations.     Cloth,  $2.     {Just  Ready.) 
The  book  is  written  in  a  careful  and  logical  man- 1  memories  in  respect  lo  the   features  of  some  affec- 
ner,  aud  though  extremely  cocci^e,  we  have  failed  |  tions. — C'inciti7iati  Med.  News,  Jan   1S50. 
to  notice  auy  evidence  of  ambiguity.     It  is  rendered  j      The  author  is  to  be  ctngralulated  upou  the  very 
more  compact  and  homogeneous  by  frequent  refer-  |  successful  manner  in  which  he  has  accomplished  his 
euces,   by  page   uumber,   to  other   portious   of  the  j  task;   he   has  succeeded  ju   being   concise   withont 


work;  repetitions  are  thus  avoided,  and  we  have 
beea  surprised  to  find  how  much  information  our 
author  has  succeeded  in  conveying  in  so  small  a 
space.  A  careful  study  of  the  book  will  well  repay 
the  general  practitioner,  even  though  it  should 
serve  only  as  a  monitor.  It  is  particularly  useful 
in  the  latter  regard,  as  the  subject  of  treatment  is 
presented  in  a  thoroughly  con.servative  manner. — 
N.  r.  Med.  Record,  March  6,  1880. 

The  author  has  succeeded  in  touching  upon  about 
all  the  points,  operations,  diseases  of  the  eye  in 
relation  to  general  diseases,  and  has  prepared  a  very 
acceptable  book. — Cincinnati  Lancet  and  Clinic, 
Feb.  7,  18S0. 

It  is  multum  in  parvo,  containing  all  the  leading 
points  to  be  remembered  in  the  patholngy,  descrip- 


sacrificiug  clearness,  and,  including  the  whole 
ground  covered  by  more  voluminous  text-books, 
has  giveu  an  excellent  ris^nni  of  all  the  practical 
inforcjation  they  contain.  We  do  not  hesitate  to 
pronounce  Mr.  JJettleship's  hook  the  best  manual  on 
ophthalmic  surgery  for  the  use  of  students  and 
"  busy  practitioners"  with  which  we  are  acquain- 
ted.—^TO.  Joxir.  Med.  Sciences,  April,  ISSO. 

A  careful  examination  has  convinced  us  that  it  is 
the  best  work  of  its  class  that  has  come  to  our  notice. 
While  all  matter  is  condensed  to  the  utmost,  there 
aie  few  points  that  are  obscured  thereby,  and  all 
are  rendered  really  attractive  to  the  average  student. 
We  can  only  hope  that  every  medical  student  shall 
be  compelled  to  master  the  entire  volume  ere  re- 
ceiving his  degree.     General  practitioners  who  take 


tion,  and  treatment  of  diseases  of  the  eye.     It  will  |  care  of  eye  cases  would    do  well   to   refresh   their 

be  found  especially  valuable  in  preparing  for  exam-  i  memories    by  its  careful  study. — Detroit  Lancet, 
inations.     Practitioners  will  find  it  convenient  as  a    April,  ISSO. 
work  of  reference,  when  they  wish  to  refresh  their  1 


pARTER  {R.  BRUDENELL),  F.R.C.S., 

^  Ophthalmic  Surgeon  to  St.  George's  Hospital,  etc. 

A  PRACTICAL  TREATISE  ON  DISEASES  OF  THE  EYE.  Edit- 
ed, with  test-types  and  Additions,  by  John  Green,  M.D.  (of  St.  Louis,  Mo.).  In  one 
handsome  octavo  volume  of  about  500  pages,  and  124  illustrations.  Cloth,  §3  75.  {Just 
Issued. ) 

It  is  with  great  pleasure  that  we  can  endorse  the  work  [  chapter  is  devoted  to  adi.scussion  of  the  uses  and  selec- 
as  a  most  valuable  contribution  to  practical  ophthal- ;  tion  ofapectacles,  and  is  admirably  compact,  plain,  and 
mology.  Mr.  Carter  never  deviates  from  the  end  he  has  '  useful,  especially  the  paragraphs  on  the  treatment  ol 
in  view,  aud  presents  the  subject  in  a  clear  and  coucist  j  presbyopia  and  myopia.  In  conclusion,  our  thanks  are 
manner,  ea.sy  of  comprehension,  and  hence  the  more  |  due  the  author  for  many  useful  hints  in  the  great  sub- 
valuable.  We  would  especially  commend,  however,  as  iject  of  ophthalmic  surgery  and  therapeutics,  afield 
worthy  of  high  praise,  the  manner  in  which  the  thera-  !  where  of  late  years  we  glean  hut  a  few  grains  of  sound 
peutics  of  di.-;ease  of  the  eye  is  elaborated,  for  here  the  ]  wheat  from  amass  of  chaff. — iVew  York  Medical  Record , 
author  is  particularly  clear  and  practical,  where  other  '  Oct.  23,  1S75. 
writers  are  unfortunately  too  often  deficient.  The  final  I 


JXTELLS  {J.  SOELBERG), 

'  '  Professor  of  Ophthalmology  in  King's  College  Hospital,  &c. 

A  TREATISE  ON    DISEASES  OF  THE  EYE.     Third  American, 

from  the  Third  London  Edition.  Thoroughly  revised,  with  copious  additions,  by  Chas. 
S.  Bull,  M  D. ,  Surgeon  and  Pathologist  to  the  New  York  Eye  and  Ear  Infirmary.  Illus- 
trated with  about  260  engravings  on  wood,  and  six  colored  plates.  Together  with  selec- 
tions from  the  Test-types  of  Jaeger  and  Snellen.  In  one  large  ana  very  handsome 
octavo  volume  of  900  pages.     (In  Press.) 

ROWNE  {EDGAR  A.), 

Surgeo7i  to  the  Liverpool  Eye  and  Ear  Infirmary,  and  tnthe  Dispensary  for  Sl!in  Diseases. 

HOW  TO  USE  THE  OPHTHALMOSCOPE.     Being  Elementary  In- 

structionsin  Ophthalmoscopy,  arranged  forthe  Use  of  Students.  With  thirty-five  illustra- 
tions.    In  one  small  volume  royal  12mo.  of  120  pages:  cloth,  $1.     (Now  Heady.) 


B 


LAURENCE'S    HANDrBOOK    OF   OPHTHALMIC  i 
SURGERY,  for  the  n»e  of  Practitioners.     Second 
edition,  revised  and   enlarged.     With  nnmerous 
illustrations.     In  one  very  handsome  octavo  vol- 
ume, cloth,  $2  75.  I 


LAWSON'S  INJURIES  TO  THE  EYE,  ORBIT, 
AND  EYELIDS:  their  Immediate  and  Remote 
Effects.  With  aboat  one  hundred  illustrations. 
In  one  very  handsome  octavo  volume,  cloth 
*3  50. 


30    Henry  C.  Lea's  Son  &  Co.'s  Publications — (Med.  Jurisprudence). 


jyURNETT  [CHARLES  H.),  M.A,  M.D., 

J-^  Aural  Surg  to  the  Pre.sb.  Hosp.,  Surgeon-in-i.harge  of  the  Infir .  for  Dis  of  the  Ear,  Phila. 

THE    EAR,  ITS    ANATOMY,   PHYSIOLOGY,  AND   DISEASES. 

A  Practical  Treatise  for  the  Use  of  Medical  Students  and  Practitioners.  In  one  hand- 
some octavo  volume  of  615  pages,  with  eighty-seven  illustrations  :  cloth,  $4  50  ;  leather, 
$5  50  ;  half  Russia,  $6  GO.      {Now  Ready.) 

Recent  progress  in  the  investigation  of  the  structures  of  the  ear,  and  advances  made  in  the 
modes  of  treating  its  diseases,  wouldsee.ru  to  render  desirable  a  new  work  in  which  all  the  re- 
sources of  the  most  advanced  science  should  be  placed  a*  the  disposal  of  the  practitioner.  This 
it  has  been  the  aim  of  Dr.  Burnett  to  accomplish,  and  the  advantages  which  he  has  enjoyed  in 
the  special  study  of  the  subject  are  a  guarantee  that  the  result  of  his  labors  will  prove  of  service 
to  the  profession  at  large,  as  well  as  to  the  specialist  in  this  department. 

Foreraoi^t  among  Ihe  nnmerous  recent  contribu-  [  medical  studeut,  and  its  study  will  wpU  repay  the 
tions  to  aural  literaturt  will  be  ranked  this  work  j  busy  practitioner  in  the  pleasuie  he  will  derive  from 
of  Dr.  Burnett.  It  is  impossible  to  do  justicn  lo  the  agreeable  style  in  whieb  many  otherwise  dry 
thi«  volume  of  over  600  pages  in  a  necessarily  brief  ,  and  mosily  unknown  subjects  are  treattd.  To  the 
notice.  It  must  suffice  to  add  that  the  book  is  pro-  i  specialist  the  work  is  of  the  highest  v«lue,  and  his 
fusely  and  accurately  illusirated,  Ihe  references  are  '  sen.se  of  gratitude  to  Dr.  Burnett  will  we  hope,  be 
conscientiously  acknowledged,  while  the  result  has  !  proportionate  to  the  amount  of  benefit  lie  can  obtain 
been  to  produce  a  treatise  which  will  henceforth  from  the  careful  study  of  Ihe  book,  and  a  constant 
rank  with  the  classic  writings  of  Wilde  and  Von  teference  to  its  trustworthy  pages. — Edinburgh 
Trolsch.  —  The  Load.  Practitioner,  May,  1879.  ,  Med.  Jvxir.,  Ang.  1S78. 

On  account  of  the  great  advances  which  have  been  '  ^  ^he  book  is  designed  especially  for  the  use  of  stu- 
made  of  late  years  iu  otology,  and  of  the  increased  ^^^^^'^  ^f^  general  practUioners,  and  places  at  their 
interest  manifested  in  it,  the  medical  profession  will  disposal  much  valuable  ra.tenal.  .^uch  a  book  as 
welcome  this  new  work,  which  presents  clearly  and  ;  the  present  one,  we  think,  haslongbeen  needed, and 
concisely  its  present  aspect,  whilst  clearly  indi-  we  may  cougtatuate  the  author  on  his  success  in 
eating  the  direction  in  whicli  further  researches  can  ""'"§  ^}^  S'^P-  J^^'l^  student  and  practitioner  can 
be  most  profiiablv  carried  on.     Dr.  Burn.tt  from  his    ^^t"dy  the  work   with  a  gr.a    deal  of  benefit      It  is 

own   mat '   -,Jr,„,.i„„-<.    =^a  o^=ni„,v  i,ir„.,oif  .,*•    protu-ely  and    beautifully  illustrated.— iV^.  Z.  i/o*- 

the  obser\ 


t  profitablv  carried  on.  Dr.  Burn.tt  from  his  ^"t^'ly  'f^  work  wit  i  a  gr.a  deal  ol  bene 
atured  experience,  and  availing  himself  of  :  Pi::^''!^^}^  '^'"'^  i"*'^"'.'^"!'/.  ill>i«trated.-iV^ 
ervations  aud  discoveries  of  others,  has  pro-    V"'''  &a«ei/«,  Oct   lo,  IS/  / . 


duced  a  work,  which  as  a  text-book,  stands /«ci7e 
princeps  \u  our  language.  We  had  marked  several 
pa-sages  as  well  worthy  of  quotation  and  Ihe  atten- 


Dr.  Burnett  is  to  be  coin  mended  for  having  written 
the  best  book  on  the  subject  in  the  English  language, 
and   especially    for   ihe   care   and  altfutiou  he  has 


tion  of  the  general  practitioner,  but  theirnumber  and    given   to  the  scientific  side  of  the  subject. — N.  1 
the  space  at  our  command  forbid.     Perhaps  it  is  bet-     Med.  Journ.,l)6c.  Ib77. 
ter,  as  the  book  ought  to  be  in  the  hands  of  every  i 

rrAYLOR  [ALFRED    S.),M.D., 

J-  Lectrtrer  on  Med.  Jurisp.  and  Chemistry  in  Ouy's  Hospital. 

POISONS  IN  RELATION  TO  MEDICAL  JURISPRUDENCE  AND 

MEDICINE.  Third  American,  from  the  Third  and  Revised  English  Edition.  In  one 
large  octavo  volume  of  850  pages  ;  cloth,  $5  50  ;  leather,  $6  50.  (Just  Issued.) 
The  present  is  based  upon  the  two  previous  edi- 
tions •  "but  the  complete]  evision  rendered  necessaiy 
by  time  has  converted  it  iuto  a  new  work."  This 
statement  from  the  preface  contains  all  that  it  is  de- 
sired to  know  in  reference  to  the  new  edition.  The 
works  of  this  author  are  already  in  (he  library  of 
every  physician  who  is  liable  to  be  called  upon  for 
medico-legal  testimony  (and  what  one  is  not?),  so  that 
all  that  is  required  to  be  known  about  the  present 
book  is  that  the  author  has  kept  it  abreast  with  the 
times.  What  makes  it  now,  as  always,  especially 
valuable  to  the  praciitiouer  is  its  conciseness  and 
practical  character,  only  those  poisonous  substances 

T>T  THE  SAME  AUTHOR. 

MEDICAL  JURISPRUDENCE. 

by  John  J.  Reese,  M.D.,  Prcf.  of  Med. 
octavo  volume  of  nearly  900  pages.     Clo 

To  the  members  ul  the  legal  and   medical  profes- 
sion, tt  is  unnecessary  to  say  anything  commenda-  | 
tory'of  Taylor's  Medical  .lurisprudeuce.    We  might 
as  well  undertake  lo  speak  of  the  merit  ofChitty's 
Pleadings. — Chicago  Legal  News,  Oct.  Iti,  187:^. 

It  is  beyondquestion  the  most  attractive  as  well 
as  most  reliable  maaual  of  medical  jurisprudence 
published  in  the  English  language.— JTrt../oMj-na/ 
nf  Syphilography,  Oct.  1873. 

It  i  s  al  toget  her  su  peril  uous  for  us  to  offer  anything 
in  behalf  ol  a  work  on  medical  j  urisprudence  by  an 
aut h or  who  isal most  universally  esteemed  to  be  the 


being  described  which  give   rise  lo  legal  investiga- 
tions.—TAe  Clinic,  ^uv.  6,  lS7o. 

Dr.  Taylor  hat  brought  to  bear  on  the  compilation 
of  this  Volume,  stores  of  learning,  experience,  and 
practical  acquaintance  with  his  subject,  probably  far 
beyond  what  any  other  living  authority  on  toxicol- 
ogy could  have  amassed  or  utilized.  He  has  fully 
sustained  his  reputation  by  the  consummate  skill 
and  legal  acumen  he  has  displayed  iu  the  arrange- 
ment ol  the  subject-matter,  and  the  result  is  a  work 
on  Poisons  which  will  be  indispensable  to  every  stu- 
dent or  practitionerin  lawand  medicine. — Tlie  Dub- 
lin Journ.  of  Med.  Set.,  Oct.  lS7o. 


Seventh  American  Edition.  Edited 

Jurisp.  in  the  Univ.  of  Penn.  In  one  large 
th,  $5  00;  leather,  $6  00.     {Lately  Issued.) 

best  authority  on  this  specialty  in  our  language.  On 
this  point,  however,  we  will  say  that  weconsider  Dr. 
Taylor  to  be  the  safenl  medioo-legal  authority  to  fol- 
low, in  general,  with  whioh  we  are  acquainted  in  any 
language. —  Va.  Clin.  Record,  Nov.  1873. 

ThislasteditionoftheManHal  is  probably  the  best 
ofall, as  it  contains  more  material  aud  is  worked  up 
to  the  latest  views  of  the  author  as  expressed  in  the 
last  edition  of  the  Principles.  Dr.  Keese,  the  editor 
of  the  Manual,  has  done  everything  to  make  his 
workacoeptable  to  his  medical  countrymen. — if.  Y. 
Med.  Record,  Jan.  15, 1874. 


or  THE  SAME  AUTHOR. 

THE  PRINCIPLES  AND  PRACTICE  OF  MEDICAL  JURISPRU- 

DENCE.     Second  Edition,  Revised,  with  numerous  Illustrations.    In  two  large  ootavo 

volumes,  cloth,  $10  00;  leather,  $12  00 
This  great  work  is  now  recognized  in  England  as  the  fullest  and  most  authoritative  treatise  on 
every  department  of  itn  important  subject.  In  laying  it,  in  its  improved  form,  before  the  Amer- 
ican profession,  the  publisheis  trust  that  it  will  assume  the  same  position  in  this  country. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Miscellaneous).       31 


-DO BERTS  (  WILLIAM),  M.D., 

-*■•'  Lecturer  on  Medicine  in  the  Mnnehester  School  of  Medicine,  etc. 

A  PRACTICAL  TREATISE    ON  URINARY  AND  RENAL  DIS 

EASES,  including  Urinary  Deposits.  Illustrated  by  numerous  cases  and  engravings.  Third 
American,  from  the  ThirdRevised  and  Enlarged  London  Edition.  In  one  largt  and 
handsome  octavo  volume  of  over  600  pages.     Cloth,  $4.     (Jvst  Ready.) 

THOMPSON  {SIR  HENRY), 

■^  Surgeon  and  Prnfe.9f.or  of  Clinical  Surgery  to  University  College  Bo,spital . 

LECTURES  ON  DISEASES  OF  THE  URINARY  ORGANS.  With 

illustrations  on  wood.  Second  American  from  the  Third  English  Edition.  In  one  neat 
octavo  volume.     Cloth,  $2  25.     (Just  Is.iued.) 

T>Y  THE  SAME  AUTHOR.  

ON  THE  PATHOLOGY  AND  TREATMENT  OF  STRICTURE  OF 

THE  URETHRA  AND  URINARY  FISTULyE.  With  plates  and  wood-cuts.  From  the 
third  and  revised  English  edition.  In  one  very  handsome  octavo  volume,  cloth,  $3  60. 
{ Lately  Published.) 

rrUKE  {DANIEL  HACK),  M.D., 

■*■  Joint  author  of  "  The  Manual  of  Psychological  Medicine,'"  &c. 

ILLUSTRATIONS  OF  THE  INFLUENCE  OF  THE  MIND  UPON 

THE  BODY  IN  HEALTH  AND  DISEASE.  Designed  to  illustrate  the  Action  of  the 
Imagination.  Inonehandsome  octavo  volume  of  416 pages,  cloth,  $3  26.  {Lately  Issued.) 

■DLANDFORD  {G.  FIELDING),  M.D.,  F.R.C.P., 

J-^  Lecturer  on  P.iyehological  Medicine  at  the  School  of  St.  George's  Hospital,  &c. 

INSANITY  AND  ITS  TREATMENT:  Lectures  on  the  Treatment, 

Medical  and  Legal,  of  Insane  Patients.     With  a  Summary  of  the  Laws  in  force  in  the 
United  States  on  the  Confinement  of  the  Insane.     By  Isaac  Ray,  M.  D.     In  one  very 
handsome  octavo  volume  of  471  pages  ;  cloth,  $3  25. 
It  satisfies  a  want  which  mnst  have  beeii  sorely    actually  seen  in  practice  and  the  appropriate  treat 


feltby  the  busy  general  practitioners  of  this  country 
It  takes  the  form  of  a  manual  of  clinical  description 
of  the  various  forms  of  insanity,  with  a  description 
of  the  mode  of  examining  persons  suspected  of  in- 
sanity. We  call  particnlarattention  to  this  feature 
of  the  book,  as  givingit  a  unique  value  to  the  gene- 
ral practitioner.  Ifwe  pass  from  theoretical  conside- 
rations to  descriptions  of  the  varietiesof  insanity  as 


ment  for  them,  we  find  in  Dr.  Blandford's  work 
considerable  advance  over  previous  writings  on  the 
subject.  His  pictures  of  the  various  forms  of  mental 
disease  are  so  clear  and  good  that  no  readercan  fail 
to  be  struck  with  their  superiority  to  those  given  in 
Jidinary  manuals  in  the  English  language  or  (so far 
as  our  own  reading  extends )in  any  other. — Londot- 
Practitioner,  Feb.  1871. 


FEA  {HENRY  C). 

SUPERSTITION    AND   FORCE:    ESSAYS    ON   THE    WAGER    OF 

LAW,  THE  WAGER  OF  BATTLE,  THE  ORDEAL,  AND  TORTURE.     Third  Revised 
and   Enlarged  Edition.     In  one  handsome  royal  12mo.  volume  of  662  pages.     Cloth, 
$2  50.      (Just  Ready.) 
This  valuable  work  is  in  reality  a  history  of  civi-  i  more  accurate  than  either  of  the  preceding,  but. 


lization  as  interpreted  by  the  pri.gress  of  jnrispru 
dence.  ...  In  "  Soperslitiou  and  Force"  we  have  I 
a  philosophic  survey  of  the  long  period  intervening 
between  primitive  barbarity  and  civilized  enlight- 
enment. There  is  not  a  chapter  in  the  work  that 
should  not  be  most  carefully  studied,  and  however 
well  ver.^ed  the  reader  may  be  in  the  scieace  of 
jurisprud-'nce,  he  will  find  much  in  Mr.  Lea's  vol- 
ume of  which  he  was  previously  ignorant.  The 
book  is  a  valuable  addition  to  the  literature  of 
social  science. —  Westminster  Review,  Jan.  18S0. 

The  appearance  of  a  new  edition  of  Mr.  Henry  C. 
Lea's  "Superstition  and  Force"  is  a  sgn  that  our 
highest  scholarf  hip  is  not  without  honor  in  its  na- 
tive country.  Mr.  Lea  has  met  every  fresh  demand 
for  his  work  with  a  careful  rerision  of  it,  and  the 
present  edition  is  not  only  fuller  and,  if  possible, 


from  the  thorough  elaboration  is  more  like  a  har- 
monious concert  and  less  like  a  batch  of  studies. — 
The  Nation,  Aug.  1,  1S7S. 

Many  will  be  tempted  to  say  that  this,  like  the 
"Declineaud  Fall,"isune  of  the  uncriticizable  books 
Its  facts  are  in  numerable,  its  deductions  simple  and 
inevitable,  and  its  chevanx-de-frise  of  references 
bristling  and  dense  enough  to  make  the  keenest, 
stoutest,  and  be.st  equipped  assailant  think  twice 
before  advancing.  Nor  is  there  anything  contro- 
versial in  it  to  provoke  assault.  The  author  is  no 
polemic.  Though  he  obviously  feels  and  thinks 
strongly,  he  succeeds  in  attaining  impartiality. 
Whether  looked  on  as  a  picture  or  a  mirror,  a  work 
such  as  this  has  a  lasting  value. — Lippineott's 
Magazine,  Oct.  1S7S. 


B' 


>  Y  THE  SAME  A  UTHOR.    (Lately  Publi.-thed.) 

STUDIES  IN  CHURCH  HISTORY— THE  RISE  OF  THE  TEM- 
PORAL POWER— BENEFIT  OF  CLERGY— EXCOMMUNICATION.  In  one  large 
royal  12mo.  volume  of  616  pp.;  cloth,  $2  76. 

The  story  was  never  told  more  calmly  or  with  ,  iasapeculiarimportanoefortheEnglish  student, and 
greater  learning  or  wiser  thought.  We  doubt,  indeed,  |  is  a  chapter  on  Ancient  Law  likely  to  be  regarded  as 
if  any  other  study  of  this  field  can  be  compared  with  i  final.  We  can  hardly  pass  from  our  mention  of  snch 
this  for  clearness,  accuracy,  and  power.  —  CWcap'o  I  works  as  these — with  which  that  on  "Sacerdotal 
E.t;a'/ni»er,  Dec.  1870.  Celib?«cv' '  should  be  included — without  noting  the 

Mr.  Lea's  latest  work, "  Studiesin  Church  History."    literary  phenomenon  that  the  head  of  one  of  the  first 
fully  sustains  the  promise  of  the  first.   It  deals  with    American  housesisalso  the  writer  ofsomeofitsmost 
three    subjects— the  Temporal    Power,   Benefit   of  original  books.-iondo?!  ^i/ieneeum,  Jan.  7, 1 871. 
Clergy,  and  Excommunication,  the  record  of  which  I 


32 


Henry  C.  Lea-'s  Son  &  Co.'s  Publications. 


INDEX   TO    CATALOGUE. 


American  Joarnal  of  the  Medical  Sciences 
Allen's  Aoaloiuy    ..... 
Anatomical  Atlas,  by  Smith  and  Horner 
Ashton  on  the  Kectum  and  Anns 
Attfield's  Chemistry    .... 
Ashwell  on  Diseases  of  Females 
*A.shhnrst's  Surgery      .... 
Browne  on  Ophtliahuoscope  . 
Browne  on  tlie  Throat    .... 
*Burnett  on  the  Ear       .... 
*3arnesou  Diseases  of  Women    . 
Barnes'  Midwifery  .... 

Bellamy's  Surgical  Anatomy 
Bryant's  Practice  of  Surgery 
Bloxam's  Chemistry      .... 
Blandford  on  Insanity  .... 
Basham  on  Renal  Diseases  . 
Bartholow  on  Electricity 
B<triow  6  Practice  ol  Medicine    . 
Bowman's  (John  E.)  Practical  Chemistry 
*Bristowe's  Practice       .... 
*Jamstead  on  Venereal 
Bumstead  and  CuUerier'sAtlasof  Venereal 
*t)arpenter'8  Human  Physiology 
Carpenter  on  the  Use  and  Abuse  of  Alcoh 
*Cornil  and  Kanvier       .... 

Carter  on  the  Eye 

Cleland's  Dissector        .... 

Classen's  Chemistry       .... 

Clowes'  Chemistry         .... 

Century  of  American  Medicine    . 

Chadwick  on  Diseases  of  Women 

Charcot  on  the  Nervous  System    . 

Chambers  on  Diet  aud  Regimen  . 

Cbristison  and  Griffith's  Dispensatory 

Churchill's  System  of  Midwifery 

Cbnrchill  on  Puerperal  Fever 

Gondie  on  Diseases  of  Children  . 

Cooper's  (B.  B.)  Lectures  on  Surgery 

CuUerier's  Atlas  of  Venereal  Diseases 

Cyclopjedia  of  Practical  Medicine 

Duncan  on  Diseases  of  Women    . 

*Oalton's  Human  Physiology 

Davis's  Clinical  Lectures 

Uewees  on  Diseases  of  Females  . 

•  ruitt's  ModernSnrgery 

*Dunglison's  Medical  Dictionary 

Ellis's  Demonstrations  in  Anatomy 

*Siichsen'8  System  of  Surgery 

*Emmet  ou  Diseases  of  Women 

Farquharson's  Therapeutics 

Foster's  Physiology  .     . 

Fenwick's  Diagnosis     . 

Finlayson's  Cliuical  Diagnosis 

Flint  on  Kespivatory  Organs 

Flint  on  tlie  Heart 

Flint's  Practice  of  Medicine. 

Flint's  Essays 

*Flint's  Clinical  Medicine     . 

Flint  on  Phthisis    . 

Flint  on  Percussion 

Fothergill's  Handbook  ofTreatment 

Fothergill's  Antagonism  of  Therapeutic  Agi 

FDwaes's  Elementary  Chemistry 

Fox  on  Diseases  of  the  Skin 

Fuller  on   the  Lungs,  &c.     . 

Green's  Pathology  and  Morbid  Anatomy 

Greene's  Medical  Chemistry 

(3ib8on's  Surgery  . 

Glage's  Patho.ogical  Histology,  by  Leidy 

♦Gray's  Anatomy^. 

Galloway's  Analysis 

Griffith's  (R.  E.)  Universal  Formulary 

Gross  on  Urinary  Organs      . 

Gross  on  Foreign  Bi'dies  in  Air-Passages 

♦Jross's  System  of  Snrgery 

Habershon  on  the  Abdiimen  . 

Hamilton  on  Dislocations  and  Fractures 

Bartshorne's  Essentials  ofMedicine  . 

Hartsnorne's  Conspectus  of  the  MedicalSci 

Hartshorne's  Anatomy  and  Physiology 

Hamilton  on  Nervous  Diseases    . 

Heath's  Practical  Anatomy 

Hoblyn's  Medical  Dictionary     . 


nts 


PAGE 

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7 

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26 

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9S     6  j 

8  I 
IS 

41 


Hodge  on  Women  .... 

Hjdge's  Obstetrics         .... 
Hjlland'e  Medical  Notes  and  Reflections 
*Hoi  mes's  Surgery         .... 

Holden's  Landmarks  t 

H.jrner's  Anatomy  and  Histology     ...       5 
Hudson  on  Fever   .......     1£ 


PAOB 

.     21 

.     26 

14 

.     28 


Hill  on  Venereal  Diseases    .... 
Hillier's  Handbook  of  Skin  Diseases 
Tones  (C.  Handfield)  on  Nervous  Disorders 
Kna'pp's  Chemical  Technology   . 
Leas  Superstition  and  Force      .         . 
Leas  Studies  in  Church  History 

Lee  on  Syphilis 

Leishman's  Midwifery 


19 
29 
29 
9 
9 
6 
19 


20 
19 
18 
11 
31 
31 
20 
25 

La  Roche  on  Yellow  Fever 14 

La  Roche  on  Pneumonia,  &c. 

Laurence  and  Moon's  Ophthalmic  Surgery 

Lawson  on  the  Eye       .... 

Lehmann  s  Physiological  Chemistry,  2  vols 

Lehmann's  Chemical  Physiology 

Ludlow's  Manual  of  Examinations    . 

Lvons  on  Fever     ..... 

Medical  News  and  Abstract 

Morris  on  Skin  Diseases 

Meigs  on  Puerperal  Fever    . 

Miller's  Practice  of  Surgery 

Miller's  Principles  of  Surgery     . 

Montgomery  on  Pregnancy 

Nettlesbip's  Ophthalmic  Medicine 

Neill  and  Smith's  Compendium  of  Med  .  S 

Obstetrical  Journal  ... 

Parry  on  Extra-Uterine  Pregnancy 

Pavy  on  Digestion 

*Parrish's  Practical  Pharmacy    . 

Pirrie's  System  of  Surgery  . 

*Playfair'8  Midwifery  .... 

Quain  and  Sharpey's  Anatomy,  by  Leidy 

♦Reynolds'  System  of  Medicine  . 

Richardson's  Preventative  Medicine    . 

Roberts  on  Urinary  Diseases 

Ramsbotham  on  Parturition 

Remsen's  Principles  of  Chemistry 

Rigby's  Midwifery         .... 

Rodwell's  Dictionary  of  Science  . 

Siimson's  Operative  Surgery 
Swayne's  Obstetric  Aphorisms    . 

Seller  on  the  Throat       .... 

Sargent's  Minor  Surgery 

Sharpey  and  Quain's  Anatomy,  by  Leidy 

Skey's  Operative  Surgery     . 

Slade  on  Diphtheria      .... 

Schafer's  Histology        .... 

*Smith  (J  L.)  on  Children     . 

Smith  (H.  H.)  and  Horner's  Anatomical  At 

Smith  (Edward)  on  Consumption 

Smith  on  Wasting  Diseases  in  Children 

*i'till6's  Therapeutics    .... 

*Still6  &  Maisch's  Dispensatory  . 

Stnrges  on  Clinical  Medicine 

Stokes  oa  Fever 

Tanuer's  Manual  of  Clinical  Medicine 
Tanner  on  Pregnancy    .... 
Taylor's  Medical  Jurisprudence 
Taylor's  Principles  and  Practice  of  Med    J 
Taylor  on  Poisons  .... 

Tuke  on  the  Influence  of  the  Mind     . 
♦Thomas  on  Diseases  of  Females 
Thompson  on  Urinary  Organs 
Thompson  on  Stricture  .... 
Todd  on  Acute  Diseases 
Woodbury's  Practice     .... 
Walshe  on  the  Heart    .... 
Watson's  Practice  of  Physic 

Wells  on  the  .Eye 

West  on  Diseases  of  Females 

West  on  Diseases  of  Children 

West  on  Nervous  Disorders  ofChildren 

Williams  on  Consumption   . 

Wilson's  Human  Anatomy  . 

Wilson's  Handbook  of  Cutaneous  Medicis 

Wiibler's  Organic  Chemistry 

Winckel  on  Childbed    .... 


risp 


18 

21 

26 

25 

21 

29 

5 

24 

25 

14 

11 

25 

24 

7 

17 

»6 

31 

23 

9 

21 

4 

25 

21 

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28 

7 

26 

19 

7 

21 

7 

19 

21 

12 

13 

15 

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6 

23 

30 

30 

30 

31 

22 

.'<1 

31 

•14 

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20 

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19 

7 

19 


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